Provider Demographics
NPI:1700843851
Name:CLARK, JAMES ROBERT (PTA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
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:PO BOX 55270
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-5270
Mailing Address - Country:US
Mailing Address - Phone:501-604-4170
Mailing Address - Fax:501-604-3223
Practice Address - Street 1:10301 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-604-4170
Practice Address - Fax:501-604-3223
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant