Rozella Rebecca Clark

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA.0004163 Issued in CO

Practice address

1024 S Lemay Ave
Fort Collins, CO 80524-3929

Phone

(970) 495-7000

Fax

(303) 306-7753

NPI assigned

Feb 17, 2007

Sex

Female

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Rozella Rebecca Clark Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

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

{
    "created_epoch": "1171670400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1447891200000",
    "number": "1790829224",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 912215",
            "city": "DENVER",
            "state": "CO",
            "postal_code": "802912215",
            "telephone_number": "303-306-7101",
            "fax_number": "303-306-7753"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1024 S LEMAY AVE",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805243929",
            "telephone_number": "970-495-7000",
            "fax_number": "303-306-7753"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "ROZELLA",
        "middle_name": "REBECCA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-02-17",
        "last_updated": "2015-11-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "GA",
            "license": "5221",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NV",
            "license": "PA1380",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CO",
            "license": "PA.0004163",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "99487594",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "ROZELLA",
            "last_name": "CLARK",
            "middle_name": "REBECCA",
            "credential": "PA-C",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Jennifer Ann Clark, SLP
• Joann Clark, PT
• Marcy Clark, L.C.S.W.
• Michelle Clark, LPC, CAC II
• Neelofer Baig Clark, L AC RN, FNP-C
• Sean Clark, LMT
• Warren James Clark, DDS
• Wendy Clark
• Emily Paige Clarkson, RDH
• Cheyenne Clayson, PA-C

• Physician Assistant in Fort Collins, CO
• Providers in Fort Collins, CO by specialty
• Physician Assistant in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2015; 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.