| NPI Number | 1790065399 |
| Provider Name | Gina Clark |
| Credential | |
| Specialization | |
| Medical School Name | Lincoln Memorial University Medical Department |
| Graduation Year | 2011 |
| Gender | F |
| Entity Type | Individual |
| PAC ID by PECOS | 9234350166 |
| Professional Enrollment ID | I20141017002341 |
| Enumeration Date | 08/26/2011 |
| Last Update Date | 11/01/2018 |
| Business Practice address |
1505 E MAIN ST, Stigler, 74462-2913 Oklahoma View on Google Map |
| Business Practice phone | 918-967-3368 |
| Business Practice fax | 918-967-4582 |
| Mailing address |
PO BOX 179, Stigler, 74462-0179 Oklahoma View on Google Map |
| Other phone | 918-967-3368 |
| Other fax | 918-967-4582 |
| Email Address | shannonfig@domain.com Reval Email Address |
Haskell Regional Hospital, Inc in Stigler
Stigler, Oklahoma
Saint Francis Hospital Muskogee
Eastern Oklahoma Medical Center
Mercy Hospital Fort Smith
Lincoln Memorial University Medical Department
2011
| Field Name | Field Value |
|---|---|
| NPI | 1790065399 |
| 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. | |
| Entity Type | Individual |
Code describing the type of health care provider that is being assigned an NPI. Codes are:
|
|
| Is Sole Proprietor | N |
Indicate whether provider is a sole proprietor.
|
|
| Provider Last Name (Legal Name) | Clark |
| The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. | |
| Provider First Name | Gina |
| The first name of the provider, if the provider is an individual. | |
| Provider Credential Text | DO |
| The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS. | |
| Provider First Line Business Mailing Address | PO BOX 179 |
| The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''. | |
| Provider Business Mailing Address City Name | Stigler |
| The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''. | |
| Provider Business Mailing Address State Name | Oklahoma |
| The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''. | |
| Provider Business Mailing Address Postal Code | 74462-0179 |
| The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''. | |
| Provider Business Mailing Address Country Code | US |
| The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''. | |
| Provider Business Mailing Address Telephone Number | 918-967-3368 |
| The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''. | |
| Provider Business Mailing Address Fax Number | 918-967-4582 |
| The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''. | |
| Provider First Line Business Practice Location Address | 1505 E MAIN ST |
| The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. | |
| Provider Business Practice Location Address City Name | Stigler |
| The city name in the location address of the provider being identified. | |
| Provider Business Practice Location Address State Name | Oklahoma |
| The State or Province name in the location address of the provider being identified. | |
| Provider Business Practice Location Address Postal Code | 74462-2913 |
| The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. | |
| Provider Business Practice Location Address Country Code | US |
| The country code in the location address of the provider being identified. | |
| Provider Business Practice Location Address Telephone Number | 918-967-3368 |
| The telephone number associated with the location address of the provider being identified. | |
| Provider Business Practice Location Address Fax Number | 918-967-4582 |
| The fax number associated with the location address of the provider being identified. | |
| Provider Enumeration Date | 08/26/2011 |
| The date the provider was assigned a unique identifier (assigned an NPI). | |
| Last Update Date | 11/01/2018 |
| The date that a record was last updated or changed. | |
| Provider Gender Code | F |
| The code designating the provider's gender if the provider is a person. | |
| Provider Gender | Female |
| The provider's gender if the provider is a person. | |
| Healthcare Provider Taxonomy Code #1 | 207Q00000X |
| The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization. | |
| Healthcare Provider Taxonomy 1 | Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. |
| Healthcare Provider Taxonomy #1 | |
| Provider License Number 1 | 172613 |
| Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section. | |
| Provider License Number State Code 1 | NC |
| Provider License Number State Code #1 | |
| Healthcare Provider Primary Taxonomy Switch 1 | N |
Primary Taxonomy:
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| Healthcare Provider Taxonomy Code #2 | 207QS0010X |
| The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization. | |
| Healthcare Provider Taxonomy 2 | A family medicine physician that is trained to be responsible for continuous care in the field of sports medicine, not only for the enhancement of health and fitness, but also for the prevention of injury and illness. A sports medicine physician must have knowledge and experience in the promotion of wellness and the prevention of injury. Knowledge about special areas of medicine such as exercise physiology, biomechanics, nutrition, psychology, physical rehabilitation, epidemiology, physical evaluation, injuries (treatment and prevention and referral practice) and the role of exercise in promoting a healthy lifestyle are essential to the practice of sports medicine. The sports medicine physician requires special education to provide the knowledge to improve the health care of the individual engaged in physical exercise (sports) whether as an individual or in team participation. |
| Healthcare Provider Taxonomy #2 | |
| Provider License Number 2 | 5482 |
| Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section. | |
| Provider License Number State Code 2 | OK |
| Provider License Number State Code #2 | |
| Healthcare Provider Primary Taxonomy Switch 2 | Y |
Primary Taxonomy:
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