Provider Demographics
NPI:1104509116
Name:WARD, CLINT MATTHEW
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:MATTHEW
Last Name:WARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8062
Mailing Address - Country:US
Mailing Address - Phone:541-954-7983
Mailing Address - Fax:
Practice Address - Street 1:2650 E BROADVIEW AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8302
Practice Address - Country:US
Practice Address - Phone:907-631-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK164807163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)