Provider Demographics
NPI:1629027974
Name:CLARK, TIMOTHY (RPA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 OAK CT STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45430-1064
Mailing Address - Country:US
Mailing Address - Phone:937-404-1101
Mailing Address - Fax:937-404-1210
Practice Address - Street 1:1200 VESTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1304
Practice Address - Country:US
Practice Address - Phone:937-828-2051
Practice Address - Fax:937-828-2052
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007543RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant