Provider Demographics
NPI:1063072973
Name:CLARK, JOHN RILEY (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RILEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 LIGHT RD APT 102
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9231
Mailing Address - Country:US
Mailing Address - Phone:415-516-8668
Mailing Address - Fax:
Practice Address - Street 1:2700 LIGHT RD APT 102
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9231
Practice Address - Country:US
Practice Address - Phone:415-516-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007136363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical