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NPI Code Detail

MEDICARE: KRIS D CLARK PA

MEDICARE: KRIS D CLARK PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0110002643VA

General Provider Information

NPI Number : 1154318624
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRIS D CLARK PA
Provider Business Mailing Address
First Line : 5000 COX RD
Second Line :
City : GLEN ALLEN
State : VA
Zip : 23060-9263
Country : US
Telephone Number : 804-968-5700
Fax Number : 804-217-7991
Provider Business Practice Location Address
First Line : 1260 TEMPLE AVE
Second Line :
City : COLONIAL HEIGHTS
State : VA
Zip : 23834-2984
Country : US
Telephone Number : 804-518-2597
Fax Number : 804-518-2598
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/30/2005
Last Update Date : 03/22/2021

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