Provider Demographics
NPI:1275884769
Name:MUDRA, ASHLEY KLACZAK (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KLACZAK
Last Name:MUDRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:A
Other - Last Name:KLACZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6224 NW 43RD ST STE A
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-8874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6224 NW 43RD ST STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-8874
Practice Address - Country:US
Practice Address - Phone:352-332-6680
Practice Address - Fax:352-332-6604
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006689200Medicaid
FL006689200Medicaid