Provider Demographics
NPI:1770805202
Name:CLARK, SUSANNAH J (PA-C)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:J
Last Name:CLARK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:275 VARNUM AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2109
Mailing Address - Country:US
Mailing Address - Phone:978-458-4300
Mailing Address - Fax:978-458-4311
Practice Address - Street 1:275 VARNUM AVE STE 203
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2109
Practice Address - Country:US
Practice Address - Phone:978-458-4300
Practice Address - Fax:978-458-4311
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPA3930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110121498AMedicaid