Krista Jean Clark, P.T.
Individual provider Active NPI Physical Therapist · Midway, UT
NPI 1114935301 · NPPES record last updated Mar 17, 2018
Key facts
- NPI
- 1114935301
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physical Therapist 225100000X
- License
- 116187-2401 (UT)
- Practice address
- 210 E Main St Ste 111
Midway, UT 84049-6828 - Phone
- (435) 657-0123
- Fax
- (435) 657-0330
- NPI assigned
- Aug 3, 2006
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Physical Therapist in Private Practice
- Education
- Other, 1984
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
210 E Main St
Midway, UT 84049-6828
Phone (435) 657-0123
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in UT
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20120118000000 | UT | Practitioner - Physical Therapist in Private Practice | 8426089996 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 116187-2401 | UT | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wellspring Physical Therapy, LLC | Physical Therapist | Current |
Accepting new patients |
Locations
210 E Main St
Ste 111
Midway, UT 84049
Phone (435) 657-0123
37 W Main St
Midway, UT 84049
Phone (435) 657-0123
Interoperability endpoints
- krista.clark.1@14863.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 116187-2401 | UT | Yes |
Addresses
Primary practice location
210 E Main St Ste 111
Midway, UT 84049-6828
Mailing address
210 E Main St Ste 111
Midway, UT 84049-6828
Phone (435) 657-0123
Other practice location 1
37 West Main St.
Midway, UT 84049-6806
Phone (435) 657-0123
Other practice location 2
37 West Main St.
Midway, UT 84049-6806
Phone (435) 657-0123
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 67054 | Other | UT | PEHP |
| 64-00532 | Other | UT | UNITEDHEALTHCARE |
| 199209 | Other | UT | ALTIUSHEALTH ADMINISTRATO |
| 11618724000001 | Other | UT | BCBS REGENCE OF UTAH |
Other providers in Midway, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 17, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.