Healthcare Provider Details

I. General information

NPI: 1518458611
Provider Name (Legal Business Name): RYAN ALEXANDER CLARK LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W HEFNER RD
OKLAHOMA CITY OK
73120-5060
US

IV. Provider business mailing address

5012 SW 129TH CT
OKLAHOMA CITY OK
73173-8882
US

V. Phone/Fax

Practice location:
  • Phone: 405-237-5941
  • Fax:
Mailing address:
  • Phone: 405-778-4088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1060
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: