MEDICARE: PATRICIA CLARK FNP

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	363LF0000X	Family Nurse Practitioner	AP109311	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427052752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA CLARK FNP

Provider Business Mailing Address
First Line	:	114 SPROLES DR STE 101
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-3249
Country	:	US
Telephone Number	:	817-249-4100
Fax Number	:	817-249-4185

Provider Business Practice Location Address
First Line	:	114 SPROLES DR STE 101
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126
Country	:	US
Telephone Number	:	817-249-4100
Fax Number	:	817-249-4185

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	02/25/2022

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