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General NPI Number Information
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NPI Number | 1912610163
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Entity Type | Individual
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Provider Name | KATHRYN CLARK PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/03/2023
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 9556 MANCHESTER RD
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City | SAINT LOUIS
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State | MO
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Zip | 63119-1313
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Country | US
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Telephone | 314-373-5740
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Fax |
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Provider Business Mailing Address
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Address Line | 4043 SEQUOIA DR
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-7711
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Country | US
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Telephone | 636-222-2282
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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 | 085.010325
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License Number State | IL
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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 | 2024007412
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License Number State | MO
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