Provider Demographics
NPI:1629471412
Name:CLARK, PHILLIP WAYNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:WAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7927 WESTOVER PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2026
Mailing Address - Country:US
Mailing Address - Phone:405-693-5612
Mailing Address - Fax:
Practice Address - Street 1:150 E. TYSON RD
Practice Address - Street 2:
Practice Address - City:QUARTZSITE
Practice Address - State:AZ
Practice Address - Zip Code:85359-4618
Practice Address - Country:US
Practice Address - Phone:928-927-8749
Practice Address - Fax:928-927-8748
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2014034806363LF0000X
AZAP 7468363LF0000X
NMCNP-02553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily