Provider Demographics
NPI:1265556872
Name:CLARK, TOR (PA-C)
Entity type:Individual
Prefix:
First Name:TOR
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TOR
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:BROWN UNIVERSITY HEALTH SERVICE
Mailing Address - Street 2:BOX 1928
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02912-0001
Mailing Address - Country:US
Mailing Address - Phone:401-863-3953
Mailing Address - Fax:401-863-7953
Practice Address - Street 1:BROWN UNIVERSITY HEALTH SERVICE
Practice Address - Street 2:BOX 1928
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02912
Practice Address - Country:US
Practice Address - Phone:401-863-3953
Practice Address - Fax:401-863-7953
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRIPA00077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant