Provider Demographics
NPI:1659883684
Name:CLARK, BRANTRIESA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRANTRIESA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BRANTRIESA
Other - Middle Name:
Other - Last Name:HUTCHINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1829 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1829 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5728
Practice Address - Country:US
Practice Address - Phone:404-292-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
GA7631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical