1225292386 NPI number — MRS. SHARLA REBEKAH CLARK P.A-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225292386 NPI number — MRS. SHARLA REBEKAH CLARK P.A-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
SHARLA
Provider Middle Name:
REBEKAH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225292386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 BLUE LAGOON DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-500-2027
Provider Business Mailing Address Fax Number:
305-500-2155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1860 S SEGUIN AVE
Provider Second Line Business Practice Location Address:
BLDG E.
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78130-3914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-626-7770
Provider Business Practice Location Address Fax Number:
855-278-4535
Provider Enumeration Date:
07/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA03095 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA03095 . This is a "PA LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 320252502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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