MEDICARE: MS. MARY CHRISTINE CLARKE FNP

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	363LF0000X	Family Nurse Practitioner	748916	TX

General Provider Information

NPI Number	:	1922061886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY CHRISTINE CLARKE FNP

Provider Business Mailing Address
First Line	:	25518 WOUNDED KNEE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78261
Country	:	US
Telephone Number	:	210-319-8333
Fax Number	:	830-714-4621

Provider Business Practice Location Address
First Line	:	25518 WOUNDED KNEE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78261
Country	:	US
Telephone Number	:	210-319-8333
Fax Number	:	830-714-4621

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	05/14/2010

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