Provider Demographics
NPI:1639263684
Name:CLARK, JOSHUA NATHANIEL
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:NATHANIEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1882 CR 431A
Mailing Address - Street 2:
Mailing Address - City:LAKE PANASOFFKEE
Mailing Address - State:FL
Mailing Address - Zip Code:33538-4620
Mailing Address - Country:US
Mailing Address - Phone:609-408-3916
Mailing Address - Fax:
Practice Address - Street 1:1882 CR 431A
Practice Address - Street 2:
Practice Address - City:LAKE PANASOFFKEE
Practice Address - State:FL
Practice Address - Zip Code:33538-4620
Practice Address - Country:US
Practice Address - Phone:609-408-3916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant