Provider Demographics
NPI:1578527545
Name:CLARK, KRISTEN J (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:J
Last Name:CLARK
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 1:1856-14 THOMPSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1663
Mailing Address - Country:US
Mailing Address - Phone:770-534-2800
Mailing Address - Fax:770-534-2889
Practice Address - Street 1:1856-14 THOMPSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1663
Practice Address - Country:US
Practice Address - Phone:770-534-2800
Practice Address - Fax:770-534-2889
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA613657510AMedicaid
GAQ48920Medicare UPIN
GA613657510AMedicaid