Provider Demographics
NPI:1831370162
Name:CLARK, AARON LEE (PT)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2769 ASHMUN ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3730
Mailing Address - Country:US
Mailing Address - Phone:906-632-2762
Mailing Address - Fax:
Practice Address - Street 1:2769 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3730
Practice Address - Country:US
Practice Address - Phone:906-632-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5505008480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP24650001Medicare PIN