MEDICARE: MR. WILLIAM A 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	5601001772	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0C36097	OTHER		TRAVELERS MEDICARE
2	0C360971062	OTHER	MI	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	0C36097	OTHER		BCBS MICHIGAN

General Provider Information

NPI Number	:	1982605739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM A CLARK PA-C

Provider Business Mailing Address
First Line	:	3413 WOODS EDGE
Second Line	:
City	:	OKEMOS
State	:	MI
Zip	:	48864-5901
Country	:	US
Telephone Number	:	517-349-3303
Fax Number	:	517-349-4374

Provider Business Practice Location Address
First Line	:	2380 CEDAR ST
Second Line	:
City	:	HOLT
State	:	MI
Zip	:	48842-2143
Country	:	US
Telephone Number	:	517-742-4922
Fax Number	:	517-699-2904

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	06/05/2015

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Directions to “ MR. WILLIAM A CLARK PA-C” Practice Location

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