Provider Demographics
NPI:1346739737
Name:CLARK, KEITH WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
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 1:303 PAMELA DR
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-1327
Mailing Address - Country:US
Mailing Address - Phone:903-363-5038
Mailing Address - Fax:
Practice Address - Street 1:406 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3226
Practice Address - Country:US
Practice Address - Phone:903-342-6790
Practice Address - Fax:903-342-6796
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2015517225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant