=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760449821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARK A COLLINS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 MADISON AVE
-----------------------------------------------------
City | FORT ATKINSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53538-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-563-7888
-----------------------------------------------------
Fax | 920-563-7741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 249
-----------------------------------------------------
City | FORT ATKINSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53538-0249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-568-5411
-----------------------------------------------------
Fax | 920-568-4004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 1029-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 1029-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1029-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------