Provider Demographics
NPI:1841488376
Name:CLARKSON, GARY WAYNE JR (PA - C)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:WAYNE
Last Name:CLARKSON
Suffix:JR
Gender:M
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:GUTHRIE USA MEDDAC
Mailing Address - Street 2:11050 MOUNT BELVEDERE BLVD
Mailing Address - City:FT. DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-3225
Mailing Address - Fax:
Practice Address - Street 1:GUTHRIE USA MEDDAC
Practice Address - Street 2:11050 MOUNT BELVEDERE BLVD
Practice Address - City:FT. DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018632363A00000X
MDC0003621363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical