Provider Demographics
NPI:1699126508
Name:CLARK, NATHAN DANIEL
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:DANIEL
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 1:4436 CLOVERHILL TER
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-6140
Mailing Address - Country:US
Mailing Address - Phone:513-378-6308
Mailing Address - Fax:
Practice Address - Street 1:5701 DELHI RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45233-1669
Practice Address - Country:US
Practice Address - Phone:513-378-6308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program