Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 17504 | WV |
N | 207KA0200X | Allergist | 17504 | WV |
NPI | 1306838453 |
---|---|
Provider Name | James Paul Clark II |
First Address | Charleston, WV 25304 |
Second Address | Charleston, WV 25304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2005 |
Last Update Date | 24/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001722434 | BLUE CROSS BS (01) | WV |
0079196000 | (05) | WV |
5720204 | AETNA (01) | WV |
F65787 | (02) |