Provider Demographics
NPI:1154665446
Name:CLARK, TIMOTHY ROSS (PTA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ROSS
Last Name:CLARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 10TH AVE N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6372
Practice Address - Country:US
Practice Address - Phone:208-734-4264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA168225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant