Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | S1580 | TX |
NPI | 1154736643 |
---|---|
Provider Name | Summer Clark |
First Address | Amarillo, TX 79106-1799 |
Second Address | Amarillo, TX 79106-1799 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2014 |
Last Update Date | 04/06/2019 |