Provider Demographics
NPI:1093777047
Name:CLARK, BRYAN A (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-571-7061
Mailing Address - Fax:
Practice Address - Street 1:9844 S 1300 E
Practice Address - Street 2:STE 275
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4692
Practice Address - Country:US
Practice Address - Phone:801-571-7061
Practice Address - Fax:801-571-9277
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3231151206363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107021850101OtherINTERMOUNTAIN HEALTH
UT999000116008Medicaid
UT107021850101OtherINTERMOUNTAIN HEALTH
UT000012641Medicare PIN