Provider Demographics
NPI:1033293865
Name:CLYDE, WILLIS K (PT)
Entity Type:Individual
Prefix:MR
First Name:WILLIS
Middle Name:K
Last Name:CLYDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-0013
Mailing Address - Country:US
Mailing Address - Phone:435-654-0804
Mailing Address - Fax:435-654-3314
Practice Address - Street 1:190 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1600
Practice Address - Country:US
Practice Address - Phone:435-654-0804
Practice Address - Fax:435-654-3314
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117343-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000067012Medicare ID - Type Unspecified