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General NPI Number Information
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NPI Number | 1063148708
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Entity Type | Individual
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Provider Name | NICHOLAS LEE CLARK PA
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Gender | Male
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Dates
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Enumeration Date | 07/26/2022
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 1000 S LIMESTONE
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City | LEXINGTON
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State | KY
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Zip | 40536
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Country | US
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Telephone | 859-323-9057
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Fax | 859-323-9502
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Provider Business Mailing Address
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Address Line | 2854 NE HICKORY RIDGE AVE
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City | JENSEN BEACH
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State | FL
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Zip | 34957-4865
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Country | US
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Telephone | 937-515-3043
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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