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General NPI Number Information
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NPI Number | 1871790725
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Entity Type | Individual
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Provider Name | SUDABEH CLARK PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/02/2007
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Last Update Date | 12/28/2022
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Provider Practice Location Address
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Address Line | 8275 S SUPERNAL WAY
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City | COTTONWOOD HEIGHTS
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State | UT
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Zip | 84121-6023
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Country | US
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Telephone | 310-963-9404
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Fax |
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Provider Business Mailing Address
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Address Line | 8275 S SUPERNAL WAY
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City | COTTONWOOD HEIGHTS
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State | UT
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Zip | 84121-6023
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Country | US
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Telephone | 310-963-9404
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 11172710-1206
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA 19540
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License Number State | CA
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