Provider Demographics
NPI:1841228335
Name:CLARK, ADELE (PA)
Entity type:Individual
Prefix:
First Name:ADELE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-9258
Practice Address - Street 1:4618 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3520
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-9258
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC189348OtherMEDCOST
NC7825786OtherAETNA
S57399Medicare UPIN
NC7825786OtherAETNA