Individual
MARK D CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP
Contact information
Practice address
102 BARRETT ST, GAINESVILLE, GA 30501-1356
(770) 540-4274
Mailing address
102 BARRETT ST, GAINESVILLE, GA 30501-1356
(770) 540-4274
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
RN128712
GA
363LA2100X
Acute Care Nurse Practitioner
Primary
RN128712
GA
363LA2200X
Adult Health Nurse Practitioner
RN128712
GA
363LG0600X
Gerontology Nurse Practitioner
RN128712
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06423272
AMERIGROUP
GA
01
—
1738523
WELLCARE
GA
05
—
615230572C
—
GA
05
—
615230572D
—
GA
05
—
615230572E
—
GA
05
—
615230572F
—
GA
Enumeration date
06/29/2005
Last updated
02/05/2021
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