Provider Demographics
NPI:1508530510
Name:CLARK, DARRON
Entity Type:Individual
Prefix:
First Name:DARRON
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 1:236 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-6815
Mailing Address - Country:US
Mailing Address - Phone:507-513-3385
Mailing Address - Fax:
Practice Address - Street 1:1875 19TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1633
Practice Address - Country:US
Practice Address - Phone:507-282-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2039208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA2039OtherPTA LICENSE NUMBER