Healthcare Provider Details

I. General information

NPI: 1952830226
Provider Name (Legal Business Name): BRENT CLARK FNP, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 01/08/2024
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17101 SNOWMOBILE LN STE 114
EAGLE RIVER AK
99577-7043
US

IV. Provider business mailing address

2440 E TUDOR RD # 781
ANCHORAGE AK
99507-1185
US

V. Phone/Fax

Practice location:
  • Phone: 907-562-2211
  • Fax:
Mailing address:
  • Phone: 907-545-4531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number122126
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: