Healthcare Provider Details

I. General information

NPI: 1912610163
Provider Name (Legal Business Name): KATHRYN CLARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9556 MANCHESTER RD
SAINT LOUIS MO
63119-1313
US

IV. Provider business mailing address

4043 SEQUOIA DR
EDWARDSVILLE IL
62025-7711
US

V. Phone/Fax

Practice location:
  • Phone: 314-373-5740
  • Fax:
Mailing address:
  • Phone: 636-222-2282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010325
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024007412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: