Provider Demographics
NPI:1750315792
Name:BRINTON, CLARK (CRNA)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:BRINTON
Suffix:
Gender:M
Credentials:CRNA
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 2203
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2203
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 3104
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6308
Practice Address - Country:US
Practice Address - Phone:208-373-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-26699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered