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NPI Code Detail

MEDICARE: STACEY CLARK PA

MEDICARE: STACEY 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
1363AM0700XMedical Physician Assistant2511AZ
2363A00000XPhysician Assistant0622NH

Other Identifiers

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

General Provider Information

NPI Number : 1710968763
Entity Type Code : Individual
Provider Name (Legal Business Name) : STACEY CLARK PA
Provider Business Mailing Address
First Line : 4 CRESCENT ST
Second Line :
City : PENACOOK
State : NH
Zip : 03303-1412
Country : US
Telephone Number : 603-753-4302
Fax Number :
Provider Business Practice Location Address
First Line : 4 CRESCENT ST.
Second Line :
City : PENACOOK
State : NH
Zip : 03303-1412
Country : US
Telephone Number : 603-753-4302
Fax Number : 603-227-7570
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/08/2005
Last Update Date : 09/30/2022

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Directions to “ STACEY CLARK PA” Practice Location

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