MEDICARE: RICHARD O CLARK PAC

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	PA000270	FL

General Provider Information

NPI Number	:	1932109105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD O CLARK PAC

Provider Business Mailing Address
First Line	:	1717 N E ST
Second Line	:	SUITE 331
City	:	PENSACOLA
State	:	FL
Zip	:	32501-6339
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 N E ST
Second Line	:	SUITE 331
City	:	PENSACOLA
State	:	FL
Zip	:	32501-6339
Country	:	US
Telephone Number	:	850-444-1717
Fax Number	:	850-444-1755

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	09/11/2007

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Directions to “ RICHARD O CLARK PAC” Practice Location

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