Provider Demographics
NPI:1104393834
Name:CLARK, WAREN G JR
Entity Type:Individual
Prefix:MR
First Name:WAREN
Middle Name:G
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 N FM 1417 APT 1414
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-3468
Mailing Address - Country:US
Mailing Address - Phone:469-975-9535
Mailing Address - Fax:
Practice Address - Street 1:3301 N FM 1417 APT 1414
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-3468
Practice Address - Country:US
Practice Address - Phone:469-975-9535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle