Healthcare Provider Details

I. General information

NPI: 1609465772
Provider Name (Legal Business Name): STEPHEN ALEXANDER CLARK CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 STATE ST
NEW ALBANY IN
47150-4990
US

IV. Provider business mailing address

7904 MEYER LOOP
SELLERSBURG IN
47172-2842
US

V. Phone/Fax

Practice location:
  • Phone: 812-944-7701
  • Fax:
Mailing address:
  • Phone: 812-207-0316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number75000066A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: