Basic Information
| Provider Information | |||||||||
| NPI: | 1376966119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 SANTA BARBARA BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339912038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 5216 CLAYTON CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339072116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393438260 | ||||||||
| FaxNumber: | 2393438261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0005308 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 9107712 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.