Provider Demographics
NPI:1952015802
Name:CLARK, CRAIG ANSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ANSON
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 1:5911 GRINNELL DR
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-7046
Mailing Address - Country:US
Mailing Address - Phone:951-733-4650
Mailing Address - Fax:
Practice Address - Street 1:3579 ARLINGTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3915
Practice Address - Country:US
Practice Address - Phone:951-341-9333
Practice Address - Fax:951-341-9330
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100262083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10026OtherPHYSICIAN ASSISTANT