Provider Demographics
NPI:1255478111
Name:CLARK, MICHAEL ANTHONY (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 CREEKSIDE DR
Mailing Address - Street 2:APT: 2424
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3838
Mailing Address - Country:US
Mailing Address - Phone:513-638-5232
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-366-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 199634163WC0400X
CA741297163WE0003X, 163WC0200X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine