1578853883 NPI number — MR. NATHAN BLAINE CLARK APRN

Table of content: MR. NATHAN BLAINE CLARK APRN (NPI 1578853883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578853883 NPI number — MR. NATHAN BLAINE CLARK APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
NATHAN
Provider Middle Name:
BLAINE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578853883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2004 MELROSE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42071-4700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-293-0443
Provider Business Mailing Address Fax Number:
270-761-9356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 INDUSTRIAL ROAD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-761-9355
Provider Business Practice Location Address Fax Number:
270-761-9356
Provider Enumeration Date:
04/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3006900 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3006900 . This is a "ARNP LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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