Provider Demographics
NPI:1861520504
Name:CLARK, CHRISTINA MACDONALD FRASER (MSNFNP)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:MACDONALD FRASER
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSNFNP
Other - Prefix:
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Mailing Address - Street 1:509 TAMALPAIS DR
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2659
Mailing Address - Country:US
Mailing Address - Phone:415-381-4735
Mailing Address - Fax:
Practice Address - Street 1:330 ELLIS ST
Practice Address - Street 2:GLIDE HEALTH SERVICES
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2735
Practice Address - Country:US
Practice Address - Phone:415-674-6130
Practice Address - Fax:415-673-1037
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC367540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA98809Medicare UPIN