Healthcare Provider Details

I. General information

NPI: 1174455463
Provider Name (Legal Business Name): CHRISTOPHER WAYNE CLARK AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 SUNSET CT
WEST COLUMBIA SC
29169-2429
US

IV. Provider business mailing address

131 SUNSET CT
WEST COLUMBIA SC
29169-2429
US

V. Phone/Fax

Practice location:
  • Phone: 803-796-2222
  • Fax: 803-796-7839
Mailing address:
  • Phone: 803-791-2000
  • Fax: 803-796-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: