MEDICARE: MICHAEL DEAN CLARK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	420-023	WI

General Provider Information

NPI Number	:	1033108014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DEAN CLARK PA-C

Provider Business Mailing Address
First Line	:	2629 FOX RIVER PKWY
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53189-7876
Country	:	US
Telephone Number	:	262-521-1674
Fax Number	:

Provider Business Practice Location Address
First Line	:	3805B SPRING ST
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-1641
Country	:	US
Telephone Number	:	262-687-4201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	04/19/2026

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