Provider Demographics
NPI:1952830226
Name:CLARK, BRENT (FNP, NP-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 E TUDOR RD # 781
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1185
Mailing Address - Country:US
Mailing Address - Phone:907-545-4531
Mailing Address - Fax:
Practice Address - Street 1:17101 SNOWMOBILE LN STE 114
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7043
Practice Address - Country:US
Practice Address - Phone:907-562-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK122126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily