Provider Demographics
NPI:1942971312
Name:CLARK, BRYAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8010 KAUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-7210
Mailing Address - Country:US
Mailing Address - Phone:719-760-9747
Mailing Address - Fax:
Practice Address - Street 1:109 WILSON AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-7521
Practice Address - Country:US
Practice Address - Phone:304-291-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0017192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000021913OtherBOARD OF CERTIFICATION
WVAT001719OtherWEST VIRGINIA LICENSURE