Provider Demographics
NPI:1215671334
Name:CLARK, CORBIN ROSS
Entity type:Individual
Prefix:
First Name:CORBIN
Middle Name:ROSS
Last Name:CLARK
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 1:9671 WILTSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-4885
Mailing Address - Country:US
Mailing Address - Phone:209-769-5473
Mailing Address - Fax:
Practice Address - Street 1:2111 BELCOURT AVE STE 201
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-3540
Practice Address - Country:US
Practice Address - Phone:615-322-2377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program