=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962806786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CURTIS CLARK ACNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2014
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4063 W 12600 S # SABS
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-935-8180
-----------------------------------------------------
Fax | 801-931-2307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4063 W 12600 S # SABS
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-935-8180
-----------------------------------------------------
Fax | 801-931-2307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 5609506-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------