Provider Demographics
NPI:1740003805
Name:CLARK, JOSEPH LEWIS
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEWIS
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5353
Mailing Address - Fax:
Practice Address - Street 1:159 HARTLEY WAY
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-2471
Practice Address - Country:US
Practice Address - Phone:540-921-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110010546363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty