# KELLAN FITZGERALD CLARK

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1134539091
- **Gender:** Man
- **Credential:** DO

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208800000X | Urology Physician | MED-PHYS-LIC-71931 | MT | Yes |

## Other

- **Enumeration date:** 04/30/2014
- **Last updated:** 11/12/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100004016 | — | MT |
| 05 | — | 1134539091 | — | ID |