MEDICARE: MRS. KARMEN RENEE 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	PA075	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619035029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KARMEN RENEE CLARK PA-C

Provider Business Mailing Address
First Line	:	6212 BROWNING DR.
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564
Country	:	US
Telephone Number	:	228-238-7443
Fax Number	:

Provider Business Practice Location Address
First Line	:	3631 BIENVILLE BLVD
Second Line	:	SUITE A
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-5702
Country	:	US
Telephone Number	:	228-818-9620
Fax Number	:	228-818-9750

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	05/02/2022

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