Provider Demographics
NPI:1518458611
Name:CLARK, RYAN ALEXANDER (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:ALEXANDER
Last Name:CLARK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4194
Mailing Address - Country:US
Mailing Address - Phone:405-778-4088
Mailing Address - Fax:
Practice Address - Street 1:2901 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2843
Practice Address - Country:US
Practice Address - Phone:405-735-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer