MR. DALLAS LAYNE CLARK P.T.
Complete NPI Record 1972693497
Physical Therapist in Diamondville, WY
Active since October 13, 2006Accepts Medicare Assignment
Complete NPI Dataset
This page contains the complete raw NPPES record for Mr. Dallas Layne Clark, P.T. (NPI 1972693497), an individual physical therapist provider in Diamondville, WY. All 50 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
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Registry File Document Utilities
- NPI: 1972693497 Field 1/50
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 1 Field 2/50
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Provider Last Name Legal Name: CLARK Field 3/50
- The last name of the provider. If the provider is an individual, this is the legal name.
- Provider First Name: DALLAS Field 4/50
- The first name of the provider, if the provider is an individual.
- Provider Middle Name: LAYNE Field 5/50
- The middle name of the provider, if the provider is an individual.
- Provider Name Prefix Text: MR. Field 6/50
- The name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
- Provider Credential Text: P.T. Field 7/50
- 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 152 Field 8/50
- 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: LAKETOWN Field 9/50
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: UT Field 10/50
- 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: 840380152 Field 11/50
- 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 If outside U S : US Field 12/50
- 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: 4359463512 Field 13/50
- 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: 4359462311 Field 14/50
- 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: 20 ADAVILLE DRIVE Field 15/50
- 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 Second Line Business Practice Location Address: SUITE 10 Field 16/50
- The second 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: DIAMONDVILLE Field 17/50
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: WY Field 18/50
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 83116 Field 19/50
- 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 If outside U S : US Field 20/50
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 3078771000 Field 21/50
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 3078771000 Field 22/50
- The fax number associated with the location address of the provider being identified.
- Provider Gender Code: M Field 25/50
- The code designating the provider's gender if the provider is a person.
- Healthcare Provider Taxonomy Code 1: 225100000X Field 26/50
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 1: 802 Field 27/50
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 1: WY Field 28/50
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 1: Y Field 29/50
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 2: 225100000X Field 30/50
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 2: 6293691-2401 Field 31/50
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 2: UT Field 32/50
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 2: N Field 33/50
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: 313318 Field 34/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 01 Field 35/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: WY Field 36/50
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 1: BLUE CROSS BLUE SHIELD Field 37/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 2: 2282218 Field 38/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 01 Field 39/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 2: WY Field 40/50
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 2: FIRST HEALTH PROVIDER NUM Field 41/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 3: 11433480 Field 42/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 3: 01 Field 43/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 3: WY Field 44/50
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 3: CAQH PROVIDER ID Field 45/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 4: 5586872 Field 46/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 4: 01 Field 47/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 4: WY Field 48/50
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 4: CCN PROVIDER NUMBER Field 49/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Is Sole Proprietor: N Field 50/50
- Indicates whether the provider is registered as a sole proprietor. This is a single-character code: "Y" means the provider operates as a sole proprietor, and "N" means they do not.
Other Provider Identifiers 5
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
5586872 Other
Identifier 1/5State: WY · Issuer: Ccn Provider Number
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
313318 Other
Identifier 2/5State: WY · Issuer: Blue Cross Blue Shield
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
W20137 Medicare PIN
Identifier 3/5State: WY
Medicare PIN: Used in legacy data fields alongside a healthcare provider's National Provider Identifier (NPI) to designate legacy Medicare provider numbers.
Medicare PIN: Used in legacy data fields alongside a healthcare provider's National Provider Identifier (NPI) to designate legacy Medicare provider numbers.
11433480 Other
Identifier 4/5State: WY · Issuer: Caqh Provider Id
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
2282218 Other
Identifier 5/5State: WY · Issuer: First Health Provider Num
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
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