Basic Information
| Provider Information | |||||||||
| NPI: | 1912017039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035314522 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035312668 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/23/2017 | ||||||||
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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 | 367500000X | 074887 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 183309707 | 05 | TX | MEDICAID | 75-0976930-005 | 01 | TX | TRICARE | OTHER | P01877259 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 183309702 | 05 | TX | MEDICAID | 75-2771569-008 | 01 | TRICARE | OTHER | 183309703 | 05 | TX | MEDICAID | 88839U | 01 | TX | BCBS | OTHER | 138309701 | 05 | TX | MEDICAID | P01246269 | 01 | TX | RAIL ROAD | OTHER | 86167U | 01 | TX | BCBS | OTHER |