Healthcare Provider Details

I. General information

NPI: 1134007487
Provider Name (Legal Business Name): GRANT WILLIAM CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE
WATERLOO IA
50703-1916
US

IV. Provider business mailing address

4834 VALLEY VIEW LN
WEST DES MOINES IA
50265-5226
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-3941
  • Fax:
Mailing address:
  • Phone: 515-537-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number141166
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: