Individual
LISA MARIE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CAA
Contact information
Practice address
11100 EUCLID AVE, CLEVELAND, OH 44106-1716
(216) 844-5583
Mailing address
11100 EUCLID AVE, CLEVELAND, OH 44106-1716
(216) 844-5583
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
1000-00543
NC
367H00000X
Anesthesiologist Assistant
Primary
67000102
OH
367H00000X
Anesthesiologist Assistant
75000044A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001295036
ANTHEM PTAN
IN
01
—
1102450646
ANTHEM PTAN
IN
01
—
1215998927
TRICARE
NC
05
—
1215998927
—
NC
01
—
185M9
BCBS
NC
05
—
2438348
—
OH
01
—
377459
ANTHEM BCBS
OH
Enumeration date
03/31/2006
Last updated
11/25/2024
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