Basic Information
| Provider Information | |||||||||
| NPI: | 1326038035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4261 STOCKTON DRIVE SUITE LL100 | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721172962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019757456 | ||||||||
| FaxNumber: | 5019781822 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 BAPTIST HEALTH DR STE 860 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019757455 | ||||||||
| FaxNumber: | 5019753631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 197623795 | 05 | AR | MEDICAID |