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General NPI Number Information
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NPI Number | 1518492008
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Entity Type | Individual
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Provider Name | TIMOTHY JERUM CLARK NP
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Gender | Male
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Dates
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Enumeration Date | 04/22/2017
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Last Update Date | 03/30/2021
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Provider Practice Location Address
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Address Line | 246 HART AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10310-3022
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Country | US
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Telephone | 347-306-8981
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Fax |
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Provider Business Mailing Address
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Address Line | 246 HART AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10310-3022
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Country | US
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Telephone | 347-306-8981
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | SP017303
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 341667
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License Number State | NY
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