Healthcare Provider Details

I. General information

NPI: 1861307746
Provider Name (Legal Business Name): ANTHONY CLARK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 WEAVER VILLAGE WAY #104
WEAVERVILLE NC
28787
US

IV. Provider business mailing address

655 S WILLOW ST STE 128
MANCHESTER NH
03103-5723
US

V. Phone/Fax

Practice location:
  • Phone: 828-348-7119
  • Fax:
Mailing address:
  • Phone: 800-995-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP033348A
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP042973A
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP056309A
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002758
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP060501A
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: