Individual
ADELE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
4618 COUNTRY CLUB RD, WINSTON SALEM, NC 27104-3520
(336) 716-2255
(336) 716-9258
Mailing address
PO BOX 344, WINSTON-SALEM, NC 27102-0344
(336) 716-2255
(336) 716-9258
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
100690
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
189348
MEDCOST
NC
01
—
7825786
AETNA
NC
Enumeration date
06/30/2006
Last updated
10/21/2010
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