Provider Demographics
NPI:1871790725
Name:CLARK, SUDABEH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SUDABEH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8275 S SUPERNAL WAY
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6023
Mailing Address - Country:US
Mailing Address - Phone:310-963-9404
Mailing Address - Fax:
Practice Address - Street 1:8275 S SUPERNAL WAY
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-6023
Practice Address - Country:US
Practice Address - Phone:310-963-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11172710-1206363A00000X
CAPA 19540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant