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General NPI Number Information
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NPI Number | 1164841102
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Entity Type | Individual
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Provider Name | GREGORY S CLARK PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/07/2014
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Last Update Date | 01/03/2017
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Provider Practice Location Address
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Address Line | 8433 HARCOURT RD STE 100
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-2193
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Country | US
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Telephone | 317-583-7600
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Fax |
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Provider Business Mailing Address
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Address Line | 10330 N MERIDIAN ST # 300
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City | INDIANAPOLIS
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State | IN
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Zip | 46290-1024
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Country | US
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Telephone |
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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 | 10000165A
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License Number State | IN
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