Provider Demographics
NPI:1245349075
Name:CLARK, ALYSON L (PA-C)
Entity type:Individual
Prefix:MS
First Name:ALYSON
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ALYSON
Other - Middle Name:L
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4320 WORNALL RD
Mailing Address - Street 2:SUITE 50-II
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5941
Mailing Address - Country:US
Mailing Address - Phone:816-931-3312
Mailing Address - Fax:816-531-9862
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 50-II
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-931-3312
Practice Address - Fax:816-531-9862
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027389363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200004760AMedicaid
KS200004760AMedicaid