Individual
JONATHAN D CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1011 HONOR HEIGHTS DR, MUSKOGEE, OK 74401-1318
(189) 577-3000
Mailing address
6731 E 131ST PL S, BIXBY, OK 74008-3302
(918) 605-4122
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
3141
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1169860
NCCPA
—
01
—
3141
OKLAHOMA MEDICAL LICENSE
OK
Enumeration date
05/20/2014
Last updated
02/28/2023
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