Provider Demographics
NPI:1396719605
Name:CLARK, SCOTT D (ANP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GRIDER STREET
Mailing Address - Street 2:EXIGENCE HOSPITALIST OF TEAM HEALTH
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215
Mailing Address - Country:US
Mailing Address - Phone:716-898-6995
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:EXIGENCE HOSPITALIST OF TEAM HEALTH
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-6995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3043261363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00468024OtherMEDICARE RAILROAD
9513263OtherINDEPENT HEALTH
00027596001OtherUNIVERA
000528561001OtherBLUE CROSS
NY02772021Medicaid
NY02772021Medicaid