MEDICARE: DR. LIAM GERHARDT CLARK MD

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	2084N0400X	Neurology Physician	11441506-1205	UT
2	2084N0400X	Neurology Physician	15685A	WY

General Provider Information

NPI Number	:	1871090837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LIAM GERHARDT CLARK MD

Provider Business Mailing Address
First Line	:	PO BOX 20970
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82003-7020
Country	:	US
Telephone Number	:	307-638-7757
Fax Number	:	307-638-8359

Provider Business Practice Location Address
First Line	:	2301 HOUSE AVE STE 201
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-3177
Country	:	US
Telephone Number	:	307-638-7757
Fax Number	:

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

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	01/20/2026

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