Provider Demographics
NPI:1003379769
Name:CLARK, BRADY
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2390 COUNTY ROAD I
Mailing Address - Street 2:
Mailing Address - City:MARKESAN
Mailing Address - State:WI
Mailing Address - Zip Code:53946-7502
Mailing Address - Country:US
Mailing Address - Phone:920-295-2552
Mailing Address - Fax:
Practice Address - Street 1:100 N EAST AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-3103
Practice Address - Country:US
Practice Address - Phone:262-524-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program