Provider Demographics
NPI:1124236146
Name:CLARK, CAMERON KEITH (LATC)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:KEITH
Last Name:CLARK
Suffix:
Gender:M
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W MCCORMICK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-2008
Mailing Address - Country:US
Mailing Address - Phone:316-942-4291
Mailing Address - Fax:316-942-4483
Practice Address - Street 1:3100 W MCCORMICK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-2008
Practice Address - Country:US
Practice Address - Phone:316-942-4291
Practice Address - Fax:316-942-4483
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-000372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer