Healthcare Provider Details

I. General information

NPI: 1316430564
Provider Name (Legal Business Name): NICHOLAS E. CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

110 ROANE ST
CHARLESTON WV
25302-2334
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3600
  • Fax:
Mailing address:
  • Phone: 304-344-0096
  • Fax: 304-342-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118087
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: