Provider Demographics
NPI:1609465772
Name:CLARK, STEPHEN ALEXANDER (CAA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ALEXANDER
Last Name:CLARK
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7904 MEYER LOOP
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-2842
Mailing Address - Country:US
Mailing Address - Phone:812-207-0316
Mailing Address - Fax:
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:812-944-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75000066A367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN75000066AOtherMEDICAL LICENSING BOARD