1942060355 NPI number — MATTHEW BRIAN CLARK APRN, FNP-C

Table of content: MATTHEW BRIAN CLARK APRN, FNP-C (NPI 1942060355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942060355 NPI number — MATTHEW BRIAN CLARK APRN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MATTHEW
Provider Middle Name:
BRIAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942060355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 LAYMAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42701-2523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-706-6944
Provider Business Mailing Address Fax Number:
270-706-5778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 LAYMAN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-706-6944
Provider Business Practice Location Address Fax Number:
270-706-5778
Provider Enumeration Date:
03/21/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  4017497 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com