Provider Demographics
NPI:1467568493
Name:CLARK, CHRISTOPHER MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:CLARK
Suffix:
Gender:M
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 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:350 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4850
Practice Address - Country:US
Practice Address - Phone:909-335-5500
Practice Address - Fax:909-335-6490
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA170120Medicare PIN
CAQ03127Medicare UPIN