Basic Information
| Provider Information | |||||||||
| NPI: | 1609120815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | NATASHA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | NATASHA | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | TANAGER PLACE CLINIC | ||||||||
| Address2: | 1030 5TH AVE SE, SUITE 3000 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524032416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192864545 | ||||||||
| FaxNumber: | 3193683358 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193562015 | ||||||||
| FaxNumber: | 3193538363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2012 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | F119550 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LP0808X | G119550 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | GROUP0057570 | 05 | IA | MEDICAID |