MEDICARE: MR. MARK ALLEN CLARK

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	363LP0200X	Pediatric Nurse Practitioner	0024166868	VA

General Provider Information

NPI Number	:	1407903693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ALLEN CLARK

Provider Business Mailing Address
First Line	:	22445 CONSERVANCY DR
Second Line	:
City	:	ASHBURN
State	:	VA
Zip	:	20148-8068
Country	:	US
Telephone Number	:	540-368-1044
Fax Number	:	540-368-1033

Provider Business Practice Location Address
First Line	:	111 PARK HILL DR # A
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3357
Country	:	US
Telephone Number	:	540-368-1044
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	11/07/2012

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