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NPI Code Detail

MEDICARE: PETER JAMES CLARK ATC, AT-L, CSCS, MA

MEDICARE: PETER JAMES CLARK ATC, AT-L, CSCS, MA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic TrainerA160047423WA

General Provider Information

NPI Number : 1346511094
Entity Type Code : Individual
Provider Name (Legal Business Name) : PETER JAMES CLARK ATC, AT-L, CSCS, MA
Provider Business Mailing Address
First Line : 502 E BOONE AVE
Second Line : AD BOX 66
City : SPOKANE
State : WA
Zip : 99258-1774
Country : US
Telephone Number : 509-313-5591
Fax Number : 509-313-5789
Provider Business Practice Location Address
First Line : 502 E BOONE AVE
Second Line : AD BOX 66
City : SPOKANE
State : WA
Zip : 99258-1774
Country : US
Telephone Number : 509-313-5591
Fax Number : 509-313-5789
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/25/2012
Last Update Date : 01/25/2012

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