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General NPI Number Information
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NPI Number | 1639353493
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Entity Type | Individual
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Provider Name | CHRISTOPHER PATRICK CLARK D.O.
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Gender | Male
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Dates
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Enumeration Date | 12/28/2007
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 4700 LAS VEGAS BLVD N MIKE O CALLAGHAN FEDERAL MEDICAL CENTER
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City | NELLIS AFB
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State | NV
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Zip | 89191-6600
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Country | US
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Telephone | 702-653-2344
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Fax |
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Provider Business Mailing Address
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Address Line | 3912 SAN ESTEBAN AVE APT/SUITE
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89084-2327
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Country | US
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Telephone | 361-215-7363
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | RTP003586
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License Number State | GA
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