Provider Demographics
NPI:1679367288
Name:CLARK, NICHOLAS MCKINLEY (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MCKINLEY
Last Name:CLARK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 BOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-4020
Mailing Address - Country:US
Mailing Address - Phone:623-806-4578
Mailing Address - Fax:
Practice Address - Street 1:2336 BOXWOOD LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-4020
Practice Address - Country:US
Practice Address - Phone:623-806-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant