Provider Demographics
NPI:1427052752
Name:CLARK, PATRICIA (FNP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SPROLES DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-3249
Mailing Address - Country:US
Mailing Address - Phone:817-249-4100
Mailing Address - Fax:817-249-4185
Practice Address - Street 1:114 SPROLES DR STE 101
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126
Practice Address - Country:US
Practice Address - Phone:817-249-4100
Practice Address - Fax:817-249-4185
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP109311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150674306Medicaid
TX150674306Medicaid
TX280606YKP5Medicare PIN
TXP48866Medicare UPIN
TX280606YKPWMedicare PIN