Provider Demographics
NPI:1396134961
Name:CLARK, CHRISTINA (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING AND RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:8931 COLONIAL CENTER DR
Practice Address - Street 2:SUITE 301
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-334-6626
Practice Address - Fax:239-334-0404
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS363A00000X
FLPA9109027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL398575OtherAVMED
FL4070865OtherCIGNA
FLIMUXNOtherBCBS
FL015979600Medicaid
FL4765071OtherAETNA
FLP01652163OtherRR MEDICARE
FLIK256YMedicare PIN