Provider Demographics
NPI:1508891607
Name:CLARK, AARON D (PT)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 BLACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3047
Mailing Address - Country:US
Mailing Address - Phone:315-622-7900
Mailing Address - Fax:315-622-7144
Practice Address - Street 1:195 BLACKBERRY RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3047
Practice Address - Country:US
Practice Address - Phone:315-622-7900
Practice Address - Fax:315-622-7144
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ24641Medicare UPIN
NYRA4498Medicare ID - Type UnspecifiedPART B