Provider Demographics
NPI:1346568896
Name:CLAY, CRYSTAL LANIECE (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LANIECE
Last Name:CLAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 NEWBERRY RD STE A3
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2290
Mailing Address - Country:US
Mailing Address - Phone:352-262-6257
Mailing Address - Fax:
Practice Address - Street 1:4410 NEWBERRY RD STE A3
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2290
Practice Address - Country:US
Practice Address - Phone:352-262-6257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant