Healthcare Provider Details

I. General information

NPI: 1689863805
Provider Name (Legal Business Name): DENNIS J CLARK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 HOSPITAL DR STE 112A
STATE COLLEGE PA
16803-5500
US

IV. Provider business mailing address

1850 E PARK AVE SUITE 112
STATE COLLEGE PA
16803-6705
US

V. Phone/Fax

Practice location:
  • Phone: 814-865-3566
  • Fax: 814-863-7803
Mailing address:
  • Phone: 814-865-3566
  • Fax: 814-863-7803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052887
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMA052887
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: