Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | PA |
NPI | 1063810901 |
---|---|
Provider Name | Mark Clement |
First Address | Erie, PA 16501-1106 |
Second Address | Erie, PA 16501-1106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2014 |
Last Update Date | 09/12/2014 |