Healthcare Provider Details

I. General information

NPI: 1255733135
Provider Name (Legal Business Name): CLARK HARDGRAVE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 ZUNI RD SE
ALBUQUERQUE NM
87108-2926
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-2481
  • Fax: 505-262-0781
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0067
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: