Healthcare Provider Details

I. General information

NPI: 1649236472
Provider Name (Legal Business Name): DEBRA DOUBLET CLARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 501
PINE BLUFF AR
71603-6329
US

IV. Provider business mailing address

1609 W 40TH AVE SUITE 501
PINE BLUFF AR
71603-6329
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-3449
  • Fax: 870-535-3973
Mailing address:
  • Phone: 870-534-3449
  • Fax: 870-535-3973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA163
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: