Provider Demographics
NPI:1235540931
Name:CLARK, PAUL A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 82ND ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2827
Mailing Address - Country:US
Mailing Address - Phone:806-687-4311
Mailing Address - Fax:806-687-4313
Practice Address - Street 1:410 AVENUE G
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-3719
Practice Address - Country:US
Practice Address - Phone:806-897-0540
Practice Address - Fax:806-897-0542
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1242809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist