Provider Demographics
NPI:1013335496
Name:CLARK, RYAN PATRICK (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PATRICK
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-1620
Mailing Address - Country:US
Mailing Address - Phone:636-293-2038
Mailing Address - Fax:
Practice Address - Street 1:309 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2099
Practice Address - Country:US
Practice Address - Phone:618-932-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005075363AM0700X
MO2014009216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant