Provider Demographics
NPI:1770515967
Name:CLARK, CHRISTINE CARON (DPM)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:CARON
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34844
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-0844
Mailing Address - Country:US
Mailing Address - Phone:702-642-4405
Mailing Address - Fax:702-642-6775
Practice Address - Street 1:2421 TECH CENTER CT
Practice Address - Street 2:#108
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128
Practice Address - Country:US
Practice Address - Phone:702-642-4405
Practice Address - Fax:702-642-6775
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8702213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T67169Medicare UPIN