Provider Demographics
NPI:1417979576
Name:CLARK, BRENDA B (PHYSICIANS ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHYSICIANS ASSISTANT
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Mailing Address - Street 1:371 NC HWY 65
Mailing Address - Street 2:SUITE204 ROCKINGHAM CO. DEPT OF PUBLIC HEALTH
Mailing Address - City:WENTWORTH
Mailing Address - State:NC
Mailing Address - Zip Code:27375-0204
Mailing Address - Country:US
Mailing Address - Phone:336-342-8140
Mailing Address - Fax:336-342-8356
Practice Address - Street 1:371 NC HWY 65
Practice Address - Street 2:SUITE204 ROCKINGHAM CO. DEPT OF PUBLIC HEALTH
Practice Address - City:WENTWORTH
Practice Address - State:NC
Practice Address - Zip Code:27375-0204
Practice Address - Country:US
Practice Address - Phone:336-342-8140
Practice Address - Fax:336-342-8356
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC100487363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2745729Medicare ID - Type Unspecified