Clark O Vandegraft, PTA

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

Practice address

3614 N Rochelle LN
Peoria, IL 61604-1039

Phone

(309) 688-0350

NPI assigned

Feb 13, 2019

Last updated

Feb 13, 2019By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1550016000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1550016000000",
    "number": "1215493358",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "109 BERRY ROAD",
            "city": "MARQUETTE HEIGHTS",
            "state": "IL",
            "postal_code": "61554",
            "telephone_number": "309-840-1720"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3614 N ROCHELLE LN",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616041039",
            "telephone_number": "309-688-0350"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VANDEGRAFT",
        "first_name": "CLARK",
        "middle_name": "O",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-02-13",
        "last_updated": "2019-02-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Reuben Mari Valenzuela, M.D.
• Christopher Van Ham, PSYD
• Steven Lee Van Meeteren, MD
• Lori Van Vooren
• Caroline Vanaman
• Aaron Thomas Vangeest
• Heidi M Vanheuklon, LCPC
• Bethany Vanne, L.C.P.C.
• Holly Vannitamby, DO
• Martin Varela, OD

• Physical Therapy Assistant in Peoria, IL
• Providers in Peoria, IL by specialty
• Physical Therapy Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.