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General NPI Number Information
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NPI Number | 1629471412
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Entity Type | Individual
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Provider Name | PHILLIP WAYNE CLARK DNP
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Gender | Male
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Dates
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Enumeration Date | 10/07/2014
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Last Update Date | 05/23/2025
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Provider Practice Location Address
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Address Line | 2501 N STOCKTON HILL RD STE 108
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City | KINGMAN
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State | AZ
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Zip | 86401-4140
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Country | US
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Telephone | 928-255-5050
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Fax | 888-571-5897
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Provider Business Mailing Address
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Address Line | 2501 N STOCKTON HILL RD STE 108
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City | KINGMAN
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State | AZ
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Zip | 86401-4140
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Country | US
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Telephone | 928-255-5050
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Fax | 888-571-5897
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2014034806
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CNP-02553
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP 7468
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License Number State | AZ
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