Provider Demographics
NPI:1245278555
Name:CLUTTER, MARK REID (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:REID
Last Name:CLUTTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:3700 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1611
Practice Address - Country:US
Practice Address - Phone:440-960-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2024-11-05
Deactivation Date:2024-10-23
Deactivation Code:
Reactivation Date:2024-11-05
Provider Licenses
StateLicense IDTaxonomies
OH50.001285207P00000X
OH50001285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCLPA16006Medicare PIN
OHP13864Medicare UPIN