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General NPI Number Information
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NPI Number | 1821059403
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Entity Type | Individual
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Provider Name | BRIAN KELLY CLARK CRNA
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Gender | Male
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Dates
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Enumeration Date | 03/31/2006
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Last Update Date | 03/08/2022
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Provider Practice Location Address
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Address Line | 501 MEDICAL DR
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City | HAMPTON
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State | VA
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Zip | 23666-6080
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Country | US
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Telephone | 703-295-9360
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Fax | 703-295-9369
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Provider Business Mailing Address
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Address Line | PO BOX 37090
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City | BALTIMORE
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State | MD
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Zip | 21297-3090
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Country | US
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Telephone | 703-295-9360
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Fax | 703-295-9369
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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 | 0024165065
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License Number State | VA
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