Provider Demographics
NPI:1346511094
Name:CLARK, PETER JAMES (ATC, AT-L, CSCS, MA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:ATC, AT-L, CSCS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E BOONE AVE
Mailing Address - Street 2:AD BOX 66
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99258-1774
Mailing Address - Country:US
Mailing Address - Phone:509-313-5591
Mailing Address - Fax:509-313-5789
Practice Address - Street 1:502 E BOONE AVE
Practice Address - Street 2:AD BOX 66
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99258-1774
Practice Address - Country:US
Practice Address - Phone:509-313-5591
Practice Address - Fax:509-313-5789
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1600474232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer