Provider Demographics
NPI:1013565498
Name:CLARK, CHRISTINA MAE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-6151
Mailing Address - Country:US
Mailing Address - Phone:207-651-8072
Mailing Address - Fax:
Practice Address - Street 1:25A JUNE STREET
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073
Practice Address - Country:US
Practice Address - Phone:207-324-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPAN374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant