Provider Demographics
NPI:1528776200
Name:CLARK, BRYAN (PA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2620 Q ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-6929
Mailing Address - Country:US
Mailing Address - Phone:831-236-6468
Mailing Address - Fax:
Practice Address - Street 1:1500 21ST ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-5216
Practice Address - Country:US
Practice Address - Phone:916-443-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant