Provider Demographics
NPI:1578853883
Name:CLARK, NATHAN BLAINE (APRN)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:BLAINE
Last Name:CLARK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-4700
Mailing Address - Country:US
Mailing Address - Phone:270-293-0443
Mailing Address - Fax:270-761-9356
Practice Address - Street 1:400 INDUSTRIAL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071
Practice Address - Country:US
Practice Address - Phone:270-761-9355
Practice Address - Fax:270-761-9356
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3006900OtherARNP LICENSE