Provider Demographics
NPI:1396467874
Name:CLARK, RYAN ALEXANDER (DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ALEXANDER
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 NEW HARTFORD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1705
Mailing Address - Country:US
Mailing Address - Phone:270-684-7856
Mailing Address - Fax:
Practice Address - Street 1:3415 NEW HARTFORD RD UNIT 2
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-2055
Practice Address - Country:US
Practice Address - Phone:270-684-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist