Healthcare Provider Details

I. General information

NPI: 1679367288
Provider Name (Legal Business Name): NICHOLAS MCKINLEY CLARK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3522 N 3RD AVE
PHOENIX AZ
85013-3903
US

IV. Provider business mailing address

3522 N 3RD AVE
PHOENIX AZ
85013-3903
US

V. Phone/Fax

Practice location:
  • Phone: 602-776-7676
  • Fax: 602-705-0567
Mailing address:
  • Phone: 602-776-7676
  • Fax: 602-705-0567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11035
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: