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General NPI Number Information
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NPI Number | 1750315792
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Entity Type | Individual
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Provider Name | CLARK BRINTON CRNA
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Gender | Male
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 520 S EAGLE RD SUITE 3104
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City | MERIDIAN
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State | ID
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Zip | 83642-6308
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Country | US
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Telephone | 208-373-1200
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2203
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City | IDAHO FALLS
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State | ID
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Zip | 83403-2203
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Country | US
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Telephone | 208-525-2090
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Fax | 208-525-2662
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | N-26699
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License Number State | ID
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