Provider Demographics
NPI:1558671941
Name:STULL, CLARK EDMON (LMT)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:EDMON
Last Name:STULL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FLOWER LN
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-1346
Mailing Address - Country:US
Mailing Address - Phone:315-380-6719
Mailing Address - Fax:
Practice Address - Street 1:2605 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13211-1147
Practice Address - Country:US
Practice Address - Phone:315-455-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024325225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024325OtherNY STATE EDUCATION DEPARTMENT