MEDICARE: KRISTEN J. CLARK P.A.

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
1	363A00000X	Physician Assistant	004548	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578527545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN J. CLARK P.A.

Provider Business Mailing Address
First Line	:	133 BENMORE DR STE 100
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-4111
Country	:	US
Telephone Number	:	407-644-4883
Fax Number	:	407-644-3697

Provider Business Practice Location Address
First Line	:	133 BENMORE DR STE 100
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-4111
Country	:	US
Telephone Number	:	407-644-4483
Fax Number	:	407-644-3697

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	11/20/2024

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Directions to “ KRISTEN J. CLARK P.A.” Practice Location

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