MEDICARE: DALLAS 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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1578234357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALLAS CLARK

Provider Business Mailing Address
First Line	:	8352 W WARM SPRINGS RD STE 300A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-3631
Country	:	US
Telephone Number	:	702-851-7287
Fax Number	:

Provider Business Practice Location Address
First Line	:	8352 W WARM SPRINGS RD STE 300A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-3631
Country	:	US
Telephone Number	:	702-851-7287
Fax Number	:

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

Provider Enumeration Date	:	09/22/2021
Last Update Date	:	09/22/2021

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Directions to “ DALLAS CLARK ” Practice Location

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