Basic Information
| Provider Information | |||||||||
| NPI: | 1134648074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 871 | ||||||||
| Address2: | |||||||||
| City: | TONTITOWN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727700871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794446277 | ||||||||
| FaxNumber: | 4794446278 | ||||||||
| Practice Location | |||||||||
| Address1: | 3061 N MARKET AVE STE 4 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727033561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794446277 | ||||||||
| FaxNumber: | 4794446278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4308 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT4308 | 01 | AR | PT | OTHER | PT4308 | 01 | AR | PT LICENSE | OTHER |