Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 102892 | AK |
N | 207QA0505X | Family Doctor - Adult Medicine | 4951 | MA |
NPI | 1063775427 |
---|---|
Provider Name | Andrea May Clark |
First Address | Anchorage, AK 99503-7174 |
Second Address | Anchorage, AK 99503-7174 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2012 |
Last Update Date | 09/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1579312 | (05) | AK |