Provider Demographics
NPI:1245776160
Name:LOCKLEAR CLARK, LAUREN ASHLEIGH (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEIGH
Last Name:LOCKLEAR CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:BRYSON CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28713-0296
Mailing Address - Country:US
Mailing Address - Phone:910-410-0010
Mailing Address - Fax:828-538-4441
Practice Address - Street 1:1521 OWEN PARK LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3454
Practice Address - Country:US
Practice Address - Phone:910-223-7420
Practice Address - Fax:910-223-7452
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCW457AOtherMEDICARE PTAN
NC1245776160Medicaid