Mr Phillip Wayne Clark, NURSE PRACTITIONER is a medicare enrolled "Nurse Practitioner - Family" in Quartzsite, Arizona. His current practice location is
150 E. Tyson Rd, Quartzsite, Arizona. You can reach out to his office (for appointments etc.) via phone at
(928) 927-8749.
Mr Phillip Wayne Clark is licensed to practice in Arizona (license number AP 7468) and he also participates in the medicare program. He does not accept medicare assignments directly but he may accept medicare through third-party (refer to Reassignment section below) and may also prescribe medicare part D drugs. His NPI Number is 1629471412.
Provider's Profile
| Full Name | Mr Phillip Wayne Clark |
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| Gender | Male |
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| Speciality | Nurse Practitioner - Family |
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| Location | 150 E. Tyson Rd, Quartzsite, Arizona |
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| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
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NPI Data:
- NPI Number: 1629471412
- Provider Enumeration Date: 10/07/2014
- Last Update Date: 01/19/2015
Medicare PECOS Information:
- PECOS PAC ID: 1557671864
- Enrollment ID: I20151116002660
Medical Identifiers
Medical identifiers for Mr Phillip Wayne Clark such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
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| 1629471412 | NPI | - | NPPES |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
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| 363LF0000X | Nurse Practitioner - Family | 2014034806 (Missouri) | Secondary |
| 363LF0000X | Nurse Practitioner - Family | AP 7468 (Arizona) | Primary |
| 363LF0000X | Nurse Practitioner - Family | CNP-02553 (New Mexico) | Secondary |
Medicare Reassignments
Some practitioners may not bill the customers directly but medicare billing happens through clinics / group practice / hospitals where the provider works. Medicare reassignment of benefits is a mechanism by which practitioners allow third parties to bill and receive payment for medicare services performed by them. Mr Phillip Wayne Clark allows following entities to bill medicare on his behalf.
| Entity Name | Jewish Family & Childrens Service |
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| Entity Type | Part B Supplier - Clinic/group Practice |
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| Entity Identifiers | NPI Number: 1023174455
PECOS PAC ID: 9234028671
Enrollment ID: O20040312001009 |
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| Entity Name | Old Pueblo Healthcare Llc |
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| Entity Type | Part B Supplier - Clinic/group Practice |
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| Entity Identifiers | NPI Number: 1306890793
PECOS PAC ID: 4981607512
Enrollment ID: O20060821000095 |
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Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. Mr Phillip Wayne Clark is
enrolled with medicare and thus, if eligible, can prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
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Mr Phillip Wayne Clark, NURSE PRACTITIONER
7927 Westover Pl,
Saint Louis, MO 63130-2026
Ph: (405) 693-5612 | Mr Phillip Wayne Clark, NURSE PRACTITIONER
150 E. Tyson Rd,
Quartzsite, AZ 85359-4618
Ph: (928) 927-8749 |
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