MEDICARE: ANA L PACHECO CLARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	G62400	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053352948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANA L PACHECO CLARK MD

Provider Business Mailing Address
First Line	:	4700 HOEN AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7824
Country	:	US
Telephone Number	:	707-526-3360
Fax Number	:	707-526-0554

Provider Business Practice Location Address
First Line	:	4700 HOEN AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7824
Country	:	US
Telephone Number	:	707-526-3360
Fax Number	:	707-526-0554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	01/04/2012

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