Provider Demographics
NPI:1659762144
Name:KENT, KLARK RANDALL (PA-C)
Entity Type:Individual
Prefix:
First Name:KLARK
Middle Name:RANDALL
Last Name:KENT
Suffix:
Gender:M
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 1:3515 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0711
Mailing Address - Country:US
Mailing Address - Phone:903-791-9355
Mailing Address - Fax:903-831-7305
Practice Address - Street 1:3515 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0711
Practice Address - Country:US
Practice Address - Phone:903-791-9355
Practice Address - Fax:903-831-7305
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant