Healthcare Provider Details

I. General information

NPI: 1316170574
Provider Name (Legal Business Name): PATRICIA L CLARK RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 ROUTE 25A STE 2
WADING RIVER NY
11792-2014
US

IV. Provider business mailing address

271 ROUTE 25A STE 2
WADING RIVER NY
11792-2014
US

V. Phone/Fax

Practice location:
  • Phone: 631-929-1256
  • Fax: 631-929-8313
Mailing address:
  • Phone: 631-929-1256
  • Fax: 631-929-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number013420-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: