Provider Demographics
NPI:1639795487
Name:CLARK, CAMERON TAYLOR (PA-C)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:TAYLOR
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:
Practice Address - Street 1:4515 PREMIER DR STE 204
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8356
Practice Address - Country:US
Practice Address - Phone:336-802-2075
Practice Address - Fax:336-802-2076
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program