Provider Demographics
NPI:1083324099
Name:CLARK, CHRISTIAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:ALEXANDER
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:XAN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:515 S 1ST AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2157
Mailing Address - Country:US
Mailing Address - Phone:240-817-7676
Mailing Address - Fax:
Practice Address - Street 1:1036 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2870
Practice Address - Country:US
Practice Address - Phone:732-587-5339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program