Provider Demographics
NPI:1487874574
Name:CLARK, JOHN WOODROW (PTA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WOODROW
Last Name:CLARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 AGAPE LN
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155
Mailing Address - Country:US
Mailing Address - Phone:830-303-7332
Mailing Address - Fax:
Practice Address - Street 1:5410 FREDERICKSBURG RD
Practice Address - Street 2:SUITE 306 INTELISTAF HEALTHCARE
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-384-0115
Practice Address - Fax:210-384-8657
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2003034225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant