1972609436 NPI number — MR. PATRICK TIMOTHY CLARK P.A-C

Table of content: MR. PATRICK TIMOTHY CLARK P.A-C (NPI 1972609436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972609436 NPI number — MR. PATRICK TIMOTHY CLARK P.A-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
PATRICK
Provider Middle Name:
TIMOTHY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A-C
Provider Gender Code:
M

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:
1972609436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4020 US HIGHWAY 27 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEBRING
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33870-1333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-314-0020
Provider Business Mailing Address Fax Number:
863-381-0024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4020 US HIGHWAY 27 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBRING
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33870-1333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-314-0020
Provider Business Practice Location Address Fax Number:
863-381-0024
Provider Enumeration Date:
09/15/2006

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: 363AM0700X , with the licence number:  PA 2384 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com