Provider Demographics
NPI:1336259852
Name:CLEMENTS, ANN M (PA)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:LIDOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:866-400-3376
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:2915 LAKEVIEW DR STE 2021
Practice Address - Street 2:
Practice Address - City:FERN PARK
Practice Address - State:FL
Practice Address - Zip Code:32730-2056
Practice Address - Country:US
Practice Address - Phone:866-400-3376
Practice Address - Fax:407-788-8834
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290480200Medicaid
FL290480200Medicaid
FLS58385Medicare UPIN