Provider Demographics
NPI:1124280433
Name:CLARKE, KRYSTAL F (DPT)
Entity type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:F
Last Name:CLARKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SARATOGA RD
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-3412
Mailing Address - Country:US
Mailing Address - Phone:518-399-6861
Mailing Address - Fax:518-399-6864
Practice Address - Street 1:42 SARATOGA RD
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-3412
Practice Address - Country:US
Practice Address - Phone:518-399-6861
Practice Address - Fax:518-399-6864
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030408-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY56563AOtherMEDICARE