Provider Demographics
NPI:1841252160
Name:CLARK, PATRICIA H (NP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:H
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10012 KENNERLY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-692-2807
Mailing Address - Fax:314-991-0727
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-692-2807
Practice Address - Fax:314-991-0727
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO089085363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3163019Medicare PIN
MOQ46901Medicare UPIN