Provider Demographics
NPI:1942868476
Name:BRUCE, CLARISSA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:RAE
Last Name:BRUCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:RAE
Other - Last Name:KOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2148
Mailing Address - Fax:319-353-8383
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2148
Practice Address - Fax:319-353-8383
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA097767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant