Provider Demographics
NPI:1679801286
Name:CLARK, BRIAN KEITH (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:CLARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 MELBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-3960
Mailing Address - Country:US
Mailing Address - Phone:650-759-1872
Mailing Address - Fax:
Practice Address - Street 1:1407 MELBOURNE ST
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-3960
Practice Address - Country:US
Practice Address - Phone:650-759-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 2497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant