Provider Demographics
NPI:1922840495
Name:CLARK, PEYTON LAIN (PA-C)
Entity type:Individual
Prefix:MS
First Name:PEYTON
Middle Name:LAIN
Last Name:CLARK
Suffix:
Gender:F
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 1:8571 HEIRLOOM BLVD APT SUITE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE GROVE
Mailing Address - State:TN
Mailing Address - Zip Code:37046-1439
Mailing Address - Country:US
Mailing Address - Phone:262-617-5360
Mailing Address - Fax:
Practice Address - Street 1:848 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2816
Practice Address - Country:US
Practice Address - Phone:901-287-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5890363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical