Provider Demographics
NPI:1982989885
Name:CLARK, MEGAN JO (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:JO
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:JO
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8301 E PRENTICE AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2989
Mailing Address - Country:US
Mailing Address - Phone:303-771-3939
Mailing Address - Fax:303-771-4949
Practice Address - Street 1:8301 E PRENTICE AVE STE 125
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2989
Practice Address - Country:US
Practice Address - Phone:303-771-3939
Practice Address - Fax:303-771-4949
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5014363A00000X
COPA.0003925363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1982989885OtherNPI