Provider Demographics
NPI:1568435519
Name:CLAY, KRISTINE A (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:CLAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 W POWERS AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-1287
Mailing Address - Country:US
Mailing Address - Phone:254-592-2289
Mailing Address - Fax:
Practice Address - Street 1:2004 W POWERS AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-1287
Practice Address - Country:US
Practice Address - Phone:254-592-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
K17090Medicare ID - Type Unspecified
ILP00307236Medicare PIN
P73564Medicare UPIN