MEDICARE: BRIAN D. CLARK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA04747	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA04747	OTHER	TX	ST. LICENSE

General Provider Information

NPI Number	:	1306889944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN D. CLARK PA-C

Provider Business Mailing Address
First Line	:	3031 W IH 10
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-5159
Country	:	US
Telephone Number	:	210-261-1000
Fax Number	:	210-731-8678

Provider Business Practice Location Address
First Line	:	601 N FRIO ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3011
Country	:	US
Telephone Number	:	210-261-3750
Fax Number	:	210-444-1474

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/21/2015

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