Basic Information
| Provider Information | |||||||||
| NPI: | 1427413590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 E 17TH ST STE W248 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927012205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145475151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1125 E 17TH ST STE W248 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145475151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2015 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 52997 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.