Provider Demographics
NPI:1104899772
Name:CLEM, LINDA RUTH (PA)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RUTH
Last Name:CLEM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:507 BRIDGE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:POINT RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-4128
Mailing Address - Country:US
Mailing Address - Phone:510-412-0145
Mailing Address - Fax:
Practice Address - Street 1:1350 S ELISEO DR
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2011
Practice Address - Country:US
Practice Address - Phone:415-925-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 16747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ30375Medicare UPIN