=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194959940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICA FAN CLAYTON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2009
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 BON AIR RD
-----------------------------------------------------
City | GREENBRAE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94904-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-925-7174
-----------------------------------------------------
Fax | 415-898-0870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 HILL RD STE B
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-898-7649
-----------------------------------------------------
Fax | 415-898-0870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0105X
-----------------------------------------------------
Taxonomy Name | Clinical Pathology/Laboratory Medicine Physician
-----------------------------------------------------
License Number | MT195065
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | MT195065
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | A130468
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------