Provider Demographics
NPI:1780992560
Name:CLARK, CHERIE CHRISTINE-VIVONA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CHERIE
Middle Name:CHRISTINE-VIVONA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:CHERIE
Other - Middle Name:CHRISTINE
Other - Last Name:VIVONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:EDEN EMERGENCY DEPARTMENT
Mailing Address - Street 2:20103 LAKE CHABOT ROAD
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546
Mailing Address - Country:US
Mailing Address - Phone:510-727-3320
Mailing Address - Fax:510-727-2745
Practice Address - Street 1:EDEN EMERGENCY DEPARTMENT
Practice Address - Street 2:20103 LAKE CHABOT ROAD
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:510-727-3320
Practice Address - Fax:510-727-2745
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant