Provider Demographics
NPI:1407308018
Name:CLARK, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MCNATT DR APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-9024
Mailing Address - Country:US
Mailing Address - Phone:573-344-7009
Mailing Address - Fax:
Practice Address - Street 1:7785 KESWICK PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119
Practice Address - Country:US
Practice Address - Phone:573-344-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-30
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program