Basic Information
| Provider Information | |||||||||
| NPI: | 1134539091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KELLAN | ||||||||
| MiddleName: | FITZGERALD | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 WESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402345 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 N 10TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063752930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2014 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 71931 | MT | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.