Active NPI
Sudabeh Clark, PA-C
- Physician Assistant
- Cottonwood Heights, UT
National Provider Identifier
1871790725
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA 19540
- Practice address
- 8275 S Supernal Way
Cottonwood Heights, UT 84121-6023 - Phone
- (310) 963-9404
- NPI assigned
- Jul 2, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 11172710-1206 | UT | |
| Physician Assistant | 363A00000X | PA 19540 | CA | Primary |
Addresses
Primary practice location
8275 S Supernal Way
Cottonwood Heights, UT 84121-6023
Mailing address
8275 S Supernal Way
Cottonwood Heights, UT 84121-6023
Phone (310) 963-9404
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA 19540 | CA | MD | Physician Assistant |
| 11172710-1206 | UT | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1183334400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1672185600000",
"number": "1871790725",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8275 S SUPERNAL WAY",
"city": "COTTONWOOD HEIGHTS",
"state": "UT",
"postal_code": "841216023",
"telephone_number": "310-963-9404"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "8275 S SUPERNAL WAY",
"city": "COTTONWOOD HEIGHTS",
"state": "UT",
"postal_code": "841216023",
"telephone_number": "310-963-9404"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "SUDABEH",
"name_prefix": "Mrs.",
"credential": "PA-C",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-07-02",
"last_updated": "2022-12-28",
"certification_date": "2022-12-28",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "UT",
"license": "11172710-1206",
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "CA",
"license": "PA 19540",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Cottonwood Heights, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.