MEDICARE: JUSTIN CLARK PA

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	0110008301	VA
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1598205742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN CLARK PA

Provider Business Mailing Address
First Line	:	1650 17TH ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-2434
Country	:	US
Telephone Number	:	202-814-6860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 17TH ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-2434
Country	:	US
Telephone Number	:	202-814-6860
Fax Number	:

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

Provider Enumeration Date	:	03/06/2017
Last Update Date	:	03/24/2025

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Directions to “ JUSTIN CLARK PA” Practice Location

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