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General NPI Number Information
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NPI Number | 1053310516
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Entity Type | Individual
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Provider Name | TERRY LEE CLARK JR. PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 02/04/2008
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Provider Practice Location Address
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Address Line | 109 BEE ST
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City | CHARLESTON
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State | SC
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Zip | 29401-5703
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Country | US
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Telephone | 843-789-7330
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Fax |
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Provider Business Mailing Address
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Address Line | 5711 CAPTAIN KIDD RD
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City | HOLLYWOOD
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State | SC
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Zip | 29449-6803
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Country | US
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Telephone | 843-696-4290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | A475
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License Number State | SC
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