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General NPI Number Information
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NPI Number | 1467167429
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Entity Type | Individual
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Provider Name | ANDREW BENJAMIN CLARK ATC
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Gender | Male
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Dates
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Enumeration Date | 01/13/2023
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Last Update Date | 01/12/2025
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Provider Practice Location Address
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Address Line | 10700 NALL AVE
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City | OVERLAND PARK
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State | KS
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Zip | 66211-1206
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Country | US
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Telephone | 912-574-1908
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Fax |
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Provider Business Mailing Address
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Address Line | 1138 E MAIN ST
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City | ANTHONY
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State | KS
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Zip | 67003-2706
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Country | US
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Telephone | 620-842-2475
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 24-01693
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2023035873
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License Number State | MO
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