Active NPI
Amanda M Clark, ATC, LAT
- Athletic Trainer
- Ruston, LA
National Provider Identifier
1255808085
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 321844
- Practice address
- 2301 Timberline CT Apt F105
Ruston, LA 71270 - Phone
- (210) 827-3950
- NPI assigned
- Oct 30, 2018
- Last updated
- Mar 20, 2021
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 321844 | LA | Primary |
Addresses
Primary practice location
2301 Timberline CT Apt F105
Ruston, LA 71270
Mailing address
2301 Timberline CT Apt F105
Ruston, LA 71270-5292
Phone (210) 827-3950
Other practice location 1
309 Circle Dr
Corpus Christi, TX 78412-2529
Phone (210) 827-3950
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255808085 | Other | TX | BLUE CROSS BLUE SHIELD |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | Ruston | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 321844 | LA | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1540857600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1616198400000",
"number": "1255808085",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2301 TIMBERLINE CT APT F105",
"city": "RUSTON",
"state": "LA",
"postal_code": "712705292",
"telephone_number": "210-827-3950"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2301 TIMBERLINE CT APT F105",
"city": "RUSTON",
"state": "LA",
"postal_code": "71270",
"telephone_number": "210-827-3950"
}
],
"practiceLocations": [
{
"address_1": "309 Circle Dr",
"address_purpose": "LOCATION",
"city": "Corpus Christi",
"state": "TX",
"postal_code": "784122529",
"country_code": "US",
"telephone_number": "210-827-3950",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "CLARK",
"first_name": "AMANDA",
"middle_name": "M",
"credential": "ATC, LAT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-10-30",
"last_updated": "2021-03-20",
"certification_date": "2021-03-20",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "LA",
"license": "321844",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "1255808085",
"state": "TX"
}
],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "Ruston",
"affiliation": "N",
"use": "DIRECT",
"useDescription": "Direct",
"address_1": "2301 Timberline Ct Apt F105",
"city": "Ruston",
"state": "LA",
"country_code": "US",
"postal_code": "712705292",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Ruston, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 20, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.