MEDICARE: MRS. LINDSEY JOHNSON CLARK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA199666	OR

General Provider Information

NPI Number	:	1659627354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LINDSEY JOHNSON CLARK PA-C

Provider Business Mailing Address
First Line	:	1693 SW CHANDLER AVE STE 250
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3231
Country	:	US
Telephone Number	:	541-382-8819
Fax Number	:

Provider Business Practice Location Address
First Line	:	1693 SW CHANDLER AVE STE 250
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3231
Country	:	US
Telephone Number	:	541-382-8819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	07/21/2022

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