MEDICARE: STEVEN DOUGLAS 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	PA2019-0077	NM

General Provider Information

NPI Number	:	1881252658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN DOUGLAS CLARK PA-C

Provider Business Mailing Address
First Line	:	1998 MOTEL BLVD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007
Country	:	US
Telephone Number	:	575-541-5941
Fax Number	:	575-541-5048

Provider Business Practice Location Address
First Line	:	1998 MOTEL BLVD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007
Country	:	US
Telephone Number	:	575-541-5941
Fax Number	:	575-541-5048

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

Provider Enumeration Date	:	06/05/2019
Last Update Date	:	06/02/2026

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