Provider Demographics
NPI:1811921646
Name:CLARK, DEBORAH LEE (PA)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1213 RIVERSIDE AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5456
Mailing Address - Country:US
Mailing Address - Phone:252-384-4133
Mailing Address - Fax:252-384-4191
Practice Address - Street 1:1144 N ROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3353
Practice Address - Country:US
Practice Address - Phone:252-384-4133
Practice Address - Fax:252-384-4191
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-00459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS45655Medicare UPIN