Provider Demographics
NPI:1114935301
Name:CLARK, KRISTA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST STE 111
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-6828
Mailing Address - Country:US
Mailing Address - Phone:435-657-0123
Mailing Address - Fax:435-657-0330
Practice Address - Street 1:210 E MAIN ST STE 111
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049-6828
Practice Address - Country:US
Practice Address - Phone:435-657-0123
Practice Address - Fax:435-657-0330
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116187-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT67054OtherPEHP
UT64-00532OtherUNITEDHEALTHCARE
UT199209OtherALTIUSHEALTH ADMINISTRATO
UT11618724000001OtherBCBS REGENCE OF UTAH
UT005709601Medicare PIN
UT67054OtherPEHP