Provider Demographics
NPI:1881252658
Name:CLARK, STEVEN DOUGLAS (PA-C)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:DOUGLAS
Last Name:CLARK
Suffix:
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 1:1998 MOTEL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007
Mailing Address - Country:US
Mailing Address - Phone:575-541-5941
Mailing Address - Fax:575-541-5048
Practice Address - Street 1:1998 MOTEL BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007
Practice Address - Country:US
Practice Address - Phone:575-541-5941
Practice Address - Fax:575-541-5048
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant