Provider Demographics
NPI:1821275520
Name:CLARK, EMILY MOSSOTTI (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MOSSOTTI
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:ANNE
Other - Last Name:MOSSOTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1218 S BROADWAY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2759
Mailing Address - Country:US
Mailing Address - Phone:859-219-0542
Mailing Address - Fax:859-219-9433
Practice Address - Street 1:1218 S BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2759
Practice Address - Country:US
Practice Address - Phone:859-219-0542
Practice Address - Fax:859-219-9433
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100051790Medicaid
KY7100051790Medicaid