Provider Demographics
NPI:1649595174
Name:CLARK, AMY CHRISTINE (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:CHRISTINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:CHRISTINE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31235
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1235
Mailing Address - Country:US
Mailing Address - Phone:520-324-4100
Mailing Address - Fax:520-324-1406
Practice Address - Street 1:2840 E SKYLINE DR STE 230
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-8005
Practice Address - Country:US
Practice Address - Phone:520-324-1214
Practice Address - Fax:520-324-1281
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006234207Q00000X, 208D00000X
CA20A12388208D00000X
MI5101018785208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ921693Medicaid
AZ921693Medicaid