Provider Demographics
NPI:1063403483
Name:CLARK, ROBIN NICOLE (PA C)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:NICOLE
Other - Last Name:CHASTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 PARNASSUS AVE # L126
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:415-353-1238
Mailing Address - Fax:415-353-1799
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143
Practice Address - Country:US
Practice Address - Phone:415-353-1238
Practice Address - Fax:415-353-1799
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP16346363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA163460OtherBLUE SHIELD
CAOPA163460Medicaid
CAOPA163460Medicaid
CAOPA163460OtherBLUE SHIELD
CABC584ZMedicare PIN