Healthcare Provider Details

I. General information

NPI: 1609247444
Provider Name (Legal Business Name): KARA M CLARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 FEDERAL RD SUITE 201
BROOKFIELD CT
06804-2418
US

IV. Provider business mailing address

124 WYNWOOD DR
NEW MILFORD CT
06776-4231
US

V. Phone/Fax

Practice location:
  • Phone: 203-740-2593
  • Fax: 203-740-8250
Mailing address:
  • Phone: 203-740-2593
  • Fax: 203-740-8250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003391
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003391
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: