Provider Demographics
NPI:1730479569
Name:CLARK, HANA (DO)
Entity Type:Individual
Prefix:
First Name:HANA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3569 ROUND BARN CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5784
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:
Practice Address - Street 1:1801 E COTATI AVE
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3613
Practice Address - Country:US
Practice Address - Phone:707-664-2921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN