Amanda Clark, PA-C

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

6480 Issued in GA

Practice address

610 Peachtree Pkwy Ste 130
Cumming, GA 30041-9778

Phone

(770) 205-2804

Fax

(770) 205-2854

NPI assigned

Jun 11, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Interoperability endpoints

• Direct secure messaging: amanda.clark.1@14358.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Northside Urgent Care Holding, LLC

  • Urgent Care Clinic/Center
  • Atlanta, GA
  • NPI 1679962237
  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1339372800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1734048000000",
    "number": "1447512082",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "610 PEACHTREE PKWY STE 130",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300419778"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "610 PEACHTREE PKWY STE 130",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300419778",
            "telephone_number": "770-205-2804",
            "fax_number": "770-205-2854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "AMANDA",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-06-11",
        "last_updated": "2024-12-13",
        "certification_date": "2024-12-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "GA",
            "license": "6480",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Carolyn Ciccotello, COTA
• Kristen Elizabeth Cinquemano, MS, OTR/L
• Arianne Cipolla, LMSW
• Sharon F Clackum, PHARM.D., CGP, FASCP
• Clarity Vision Group, LLC
• Carolyn Denbow Clark, OTR/L
• Christina S Clark, PHARM. D.
• Elliott Cline Clark, PHARMD.
• Melissa Clark
• Victoria Elizabeth Clark, OTR

• Surgical Physician Assistant in Cumming, GA
• Providers in Cumming, GA by specialty
• Surgical Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.