Provider Demographics
NPI:1861197386
Name:CLARK, ROSS
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:MAURICE
Mailing Address - State:LA
Mailing Address - Zip Code:70555-0363
Mailing Address - Country:US
Mailing Address - Phone:337-501-2807
Mailing Address - Fax:
Practice Address - Street 1:1700 KALISTE SALOOM RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6186
Practice Address - Country:US
Practice Address - Phone:337-981-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical