=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013335496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN PATRICK CLARK PHYSICIAN ASSISTANT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2014
-----------------------------------------------------
Last Update Date | 08/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 W SAINT LOUIS ST
-----------------------------------------------------
City | WEST FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62896-2099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-932-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 HOUSTON ST
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63301-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-293-2038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 085005075
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2014009216
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------