Healthcare Provider Details

I. General information

NPI: 1730235904
Provider Name (Legal Business Name): GREGORY GLEN CLARK P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

531 ROSELANE ST NW STE 830
MARIETTA GA
30060-6979
US

V. Phone/Fax

Practice location:
  • Phone: 770-794-0477
  • Fax: 770-794-3108
Mailing address:
  • Phone: 770-794-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number1772
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: