Provider Demographics
NPI:1831061860
Name:CLARK, WILL
Entity type:Individual
Prefix:
First Name:WILL
Middle Name:
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 1:72 SUSIE TABOR RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-9425
Mailing Address - Country:US
Mailing Address - Phone:270-619-1398
Mailing Address - Fax:
Practice Address - Street 1:1205 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4968
Practice Address - Country:US
Practice Address - Phone:406-243-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTE3919822207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services