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General NPI Number Information
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NPI Number | 1629027974
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Entity Type | Individual
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Provider Name | TIMOTHY CLARK RPA-C
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Gender | Male
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Dates
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Enumeration Date | 05/06/2006
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Last Update Date | 05/02/2025
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Provider Practice Location Address
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Address Line | 1200 VESTER AVE
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City | SPRINGFIELD
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State | OH
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Zip | 45503-1304
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Country | US
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Telephone | 937-828-2051
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Fax | 937-828-2052
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Provider Business Mailing Address
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Address Line | 1430 OAK CT STE 100
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City | BEAVERCREEK
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State | OH
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Zip | 45430-1064
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Country | US
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Telephone | 937-404-1101
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Fax | 937-404-1210
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.007543RX
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License Number State | OH
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