Provider Demographics
NPI:1497202279
Name:CLARK, DEVAN (LMT)
Entity Type:Individual
Prefix:
First Name:DEVAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 N SNOW GOOSE DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-2505
Mailing Address - Country:US
Mailing Address - Phone:419-961-3818
Mailing Address - Fax:
Practice Address - Street 1:3540 N SNOW GOOSE DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-2505
Practice Address - Country:US
Practice Address - Phone:419-961-3818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK107485174400000X
AZMT-21190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist