1760559033 NPI number — MISS DORA K. CLARK PA-C

Table of content: MISS DORA K. CLARK PA-C (NPI 1760559033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760559033 NPI number — MISS DORA K. CLARK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DORA
Provider Middle Name:
K.
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-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:
1760559033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 QUAKER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST WARWICK
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02893-2283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-828-7110
Provider Business Mailing Address Fax Number:
401-825-6029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 QUAKER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST WARWICK
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02893-2283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-828-7110
Provider Business Practice Location Address Fax Number:
401-827-6364
Provider Enumeration Date:
11/29/2006

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:  PA00430 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC95067 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01280388 . This is a "RAILROAD MCR" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 1760559033 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2509391 . This is a "COVENTRY" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 7674984 . This is a "AETNA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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