Provider Demographics
NPI:1689728032
Name:CLARK, JOHN (RN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 24R
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-9610
Mailing Address - Country:US
Mailing Address - Phone:760-387-2187
Mailing Address - Fax:
Practice Address - Street 1:52 N TU SU LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8058
Practice Address - Country:US
Practice Address - Phone:760-873-8461
Practice Address - Fax:760-873-3530
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN629103163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659433191OtherORGANIZATION NPI #