Provider Demographics
NPI:1063995629
Name:CLARK, DAVID BENJAMIN (DNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BENJAMIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 FURNESS CT
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1423
Mailing Address - Country:US
Mailing Address - Phone:612-940-3132
Mailing Address - Fax:
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8758363L00000X
MN1854912363LF0000X
MN6100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily