Provider Demographics
NPI:1104112788
Name:CLARK, ROBERT BRANDON (FNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRANDON
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 420
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5491
Mailing Address - Country:US
Mailing Address - Phone:984-974-2705
Mailing Address - Fax:
Practice Address - Street 1:101 E WT HARRIS BLVD
Practice Address - Street 2:BLDG 5000 SUITE #5101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-863-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005238363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005565Medicaid
NC1104112788Medicaid
SCNP2044Medicaid
NC7005565Medicaid