Basic Information
| Provider Information | |||||||||
| NPI: | 1821106709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 SIERRA ROSE DR | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753224550 | ||||||||
| FaxNumber: | 7753224776 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 SIERRA ROSE DR | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753224550 | ||||||||
| FaxNumber: | 7753224776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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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 | 207RN0300X | 7445 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 002016889 | 05 | NV | MEDICAID |