Basic Information
| Provider Information | |||||||||
| NPI: | 1629471412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7927 WESTOVER PL | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631302026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056935612 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 150 E. TYSON RD | ||||||||
| Address2: | |||||||||
| City: | QUARTZSITE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853594618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9289278749 | ||||||||
| FaxNumber: | 9289278748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2014 | ||||||||
| LastUpdateDate: | 01/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2014034806 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP 7468 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP-02553 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.