Provider Demographics
NPI:1679656953
Name:CLARK, CHRISTINA (PAC)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PAC
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 990
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40423-0990
Mailing Address - Country:US
Mailing Address - Phone:859-239-2379
Mailing Address - Fax:859-239-6898
Practice Address - Street 1:1509 LOUISVILLE RD
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-8622
Practice Address - Country:US
Practice Address - Phone:859-239-2379
Practice Address - Fax:859-239-6898
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95000741Medicaid
KYS86391Medicare UPIN
KY95000741Medicaid