Basic Information
| Provider Information | |||||||||
| NPI: | 1013565498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | WELLS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040906151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076518072 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25A JUNE STREET | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073241488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 01/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PAN374 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.