Basic Information
| Provider Information | |||||||||
| NPI: | 1679118426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | EVA | ||||||||
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| Credential: | WHNP | ||||||||
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| OtherLastName: | TILFORD | ||||||||
| OtherFirstName: | EVA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 NE 10TH ST | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168101409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD # MS 2028 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2019 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2019023253 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363LW0102X | 2019023253 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.