Provider Demographics
NPI:1669899985
Name:CLARK, ALICIA SUZANNE (MPAP, PA-C)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:SUZANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPAP, PA-C
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:SUZANNE
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 S ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2201
Mailing Address - Country:US
Mailing Address - Phone:213-989-7700
Mailing Address - Fax:
Practice Address - Street 1:123 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2201
Practice Address - Country:US
Practice Address - Phone:213-989-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51943363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical