Provider Demographics
NPI:1811196801
Name:TEAGUE CLARK, KAREN ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:ELIZABETH
Last Name:TEAGUE CLARK
Suffix:
Gender:F
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 1:930 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6967
Mailing Address - Country:US
Mailing Address - Phone:336-890-3200
Mailing Address - Fax:336-890-3290
Practice Address - Street 1:930 3RD ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6967
Practice Address - Country:US
Practice Address - Phone:336-890-3200
Practice Address - Fax:336-890-3290
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-00326OtherNORTH CAROLINA PA LICENSE