Healthcare Provider Details

I. General information

NPI: 1841478302
Provider Name (Legal Business Name): AMANDA WILDER LARK MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4471 LONG PRAIRIE RD # 100
FLOWER MOUND TX
75028
US

IV. Provider business mailing address

4471 LONG PRAIRIE RD # 100
FLOWER MOUND TX
75028-1795
US

V. Phone/Fax

Practice location:
  • Phone: 972-362-0956
  • Fax:
Mailing address:
  • Phone: 972-362-0956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03432
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: