Provider Demographics
NPI:1235158700
Name:CLARK, CHRISTOPHER (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630326
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-0326
Mailing Address - Country:US
Mailing Address - Phone:443-332-4088
Mailing Address - Fax:410-793-0809
Practice Address - Street 1:7300 VAN DUSEN RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9463
Practice Address - Country:US
Practice Address - Phone:410-793-0791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR105705367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD019960D65Medicare PIN