MEDICARE: WESLEY ETHAN CLARK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1142982	TX

General Provider Information

NPI Number	:	1730118381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WESLEY ETHAN CLARK PT

Provider Business Mailing Address
First Line	:	931 YORK DR
Second Line	:	SUITE A
City	:	DESOTO
State	:	TX
Zip	:	75115-2043
Country	:	US
Telephone Number	:	972-296-6645
Fax Number	:	972-296-4526

Provider Business Practice Location Address
First Line	:	931 YORK DR
Second Line	:	SUITE A
City	:	DESOTO
State	:	TX
Zip	:	75115-2043
Country	:	US
Telephone Number	:	972-296-6645
Fax Number	:	972-296-4526

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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Directions to “ WESLEY ETHAN CLARK PT” Practice Location

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