Charles S Clark

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

Practice address

BLDG. H 2005 Knight Lane Attn: Medical Staff Services
Navy Medicine Support Command
Jacksonville, FL 92055-0140

Phone

(858) 361-9254

NPI assigned

Dec 23, 2009

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

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

{
    "created_epoch": "1261526400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1261526400000",
    "number": "1780913640",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3986 SHIELDS ST",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921243314",
            "telephone_number": "858-361-9254"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "BLDG. H 2005 KNIGHT LANE ATTN: MEDICAL STAFF SERVICES",
            "address_2": "NAVY MEDICINE SUPPORT COMMAND",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "920550140",
            "telephone_number": "858-361-9254"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "CHARLES",
        "middle_name": "S",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-12-23",
        "last_updated": "2009-12-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ames Benjamin Clark, BCBA, LBA
• Ashlee Hutcheson Clark, APRN
• Barrie Raye Clark, DO
• Bennie Clark Jr., DMD
• Caitlin Drew Clark, SLP-CCC
• Connie Clark
• De'Atra Pruett Clark, OT
• Demetria Angelica Clark, PA
• Destiny Sade Clark
• Elexus Kristina Clark

• Medical Physician Assistant in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Medical Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.