Provider Demographics
NPI:1114924149
Name:CLARK, RYAN N (MS, ATC/R, CSCS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:N
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, ATC/R, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8804 NE 73RD TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64158-1088
Mailing Address - Country:US
Mailing Address - Phone:816-781-0270
Mailing Address - Fax:
Practice Address - Street 1:1931 BURLINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3407
Practice Address - Country:US
Practice Address - Phone:816-241-2131
Practice Address - Fax:816-241-0551
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030222452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer