Healthcare Provider Details

I. General information

NPI: 1063441814
Provider Name (Legal Business Name): LYNN J KUGLER-CLARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W MORSE BLVD
WINTER PARK FL
32789-3731
US

IV. Provider business mailing address

701 W MORSE BLVD
WINTER PARK FL
32789-3731
US

V. Phone/Fax

Practice location:
  • Phone: 407-629-8121
  • Fax: 407-629-7250
Mailing address:
  • Phone: 407-629-8121
  • Fax: 407-629-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9100866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: