Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter | 1175 | MN |
NPI | 1205043528 |
---|---|
Provider Name | David James Clark |
First Address | Blaine, MN 55434-2931 |
Second Address | Saint Paul, MN 55114-1839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |