Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0000X | Obstetrician | MD055102L | PA |
NPI | 1215938907 |
---|---|
Provider Name | Roy R Clark |
First Address | Irwin, PA 15642-3177 |
Second Address | Irwin, PA 15642-3177 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2005 |
Last Update Date | 03/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G08614 | (02) |