Provider Demographics
NPI:1750364188
Name:CLARK, DENNIS JAY JR (PA C)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:JAY
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:PA C
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Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:110 MAGEE STREET
Mailing Address - City:GROVETON
Mailing Address - State:TX
Mailing Address - Zip Code:75845-0459
Mailing Address - Country:US
Mailing Address - Phone:936-642-0841
Mailing Address - Fax:936-642-0849
Practice Address - Street 1:110 MAGEE
Practice Address - Street 2:
Practice Address - City:GROVETON
Practice Address - State:TX
Practice Address - Zip Code:75845-4185
Practice Address - Country:US
Practice Address - Phone:936-642-0841
Practice Address - Fax:936-642-0849
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2010-07-28
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Provider Licenses
StateLicense IDTaxonomies
TXPA 02393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203876201Medicaid
TXPA 02393OtherLICENSE
TX203876202Medicaid
TX203876201Medicaid