Provider Demographics
NPI:1912610163
Name:CLARK, KATHRYN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
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 1:4043 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-7711
Mailing Address - Country:US
Mailing Address - Phone:636-222-2282
Mailing Address - Fax:
Practice Address - Street 1:9556 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1313
Practice Address - Country:US
Practice Address - Phone:314-373-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.010325363A00000X
MO2024007412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant