Basic Information
| Provider Information | |||||||||
| NPI: | 1215117593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PONTRIS | ||||||||
| MiddleName: | SAPP | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | PONTRESS | ||||||||
| OtherMiddleName: | DENISE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6308 TORREY PINES DR | ||||||||
| Address2: | |||||||||
| City: | N RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761800832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176764011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9900 BREN RD E | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553439664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005610861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 465762 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | A1007111 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.