Healthcare Provider Details

I. General information

NPI: 1972900520
Provider Name (Legal Business Name): HEATHER CLARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER STULTZ PA-C

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9815 MAIN ST STE 208
DAMASCUS MD
20872
US

IV. Provider business mailing address

9815 MAIN ST STE 208
DAMASCUS MD
20872-2099
US

V. Phone/Fax

Practice location:
  • Phone: 301-253-4004
  • Fax: 301-253-3391
Mailing address:
  • Phone: 301-253-4004
  • Fax: 301-253-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005635
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC0005635
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: