Provider Demographics
NPI:1619026119
Name:CLARK, ALAN R (PA-C)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:R
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 1:4149 CORBIN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-2918
Mailing Address - Country:US
Mailing Address - Phone:336-402-6301
Mailing Address - Fax:
Practice Address - Street 1:4601 W MARKET ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408
Practice Address - Country:US
Practice Address - Phone:336-547-9091
Practice Address - Fax:336-547-9092
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP92967Medicare UPIN