Provider Demographics
NPI:1841478302
Name:LARK, AMANDA WILDER (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:WILDER
Last Name:LARK
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4471 LONG PRAIRIE RD # 100
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1795
Mailing Address - Country:US
Mailing Address - Phone:972-362-0956
Mailing Address - Fax:
Practice Address - Street 1:4471 LONG PRAIRIE RD # 100
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-362-0956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285113102Medicaid
TX285113101Medicaid
TXTXB123637Medicare PIN
TX285113102Medicaid
TXTXB123634Medicare PIN