Provider Demographics
NPI:1194035840
Name:VANCE, CLAY
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:
Last Name:VANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 LEWELLING BLVD SPC 16
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-2261
Mailing Address - Country:US
Mailing Address - Phone:510-691-3592
Mailing Address - Fax:
Practice Address - Street 1:2100 LEWELLING BLVD SPC 16
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94579-2261
Practice Address - Country:US
Practice Address - Phone:510-691-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily