=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871414359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN CLARK FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2026
-----------------------------------------------------
Last Update Date | 07/22/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2060 DAN PROCTOR DR STE 2100
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-3895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-882-6767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 LIGHTHOUSE WAY
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31569-4079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-552-7023
-----------------------------------------------------
Fax | 912-552-7023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN-NP266514
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------