=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437981016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN CLARK PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2024
-----------------------------------------------------
Last Update Date | 10/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5104 S PINNACLE HILLS PKWY STE 1C
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-6076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-337-7345
-----------------------------------------------------
Fax | 479-239-5444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2668 E CITIZENS DR STE 5
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-595-0711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT5558
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1396643
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------