Provider Demographics
NPI:1447446174
Name:CLARKE, THERESA S (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:S
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 N RALEIGH ST STE C1
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-8613
Mailing Address - Country:US
Mailing Address - Phone:919-331-0031
Mailing Address - Fax:919-338-2627
Practice Address - Street 1:800 N RALEIGH STREET C1
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-7547
Practice Address - Country:US
Practice Address - Phone:919-331-0031
Practice Address - Fax:919-338-2627
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2010-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC103209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP45592Medicare UPIN