Healthcare Provider Details

I. General information

NPI: 1457438004
Provider Name (Legal Business Name): CHRISTA LYNN CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 DOUGLAS BLVD
GRANITE BAY CA
95746-6205
US

IV. Provider business mailing address

5220 DOUGLAS BLVD
GRANITE BAY CA
95746-6205
US

V. Phone/Fax

Practice location:
  • Phone: 916-242-2662
  • Fax: 916-242-4165
Mailing address:
  • Phone: 916-242-2662
  • Fax: 916-242-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA72524
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: