Provider Demographics
NPI:1528291069
Name:CLARK, KRISTIN MARIE JEROME (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE JEROME
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14010 SMOKETOWN RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4722
Mailing Address - Country:US
Mailing Address - Phone:201-669-8040
Mailing Address - Fax:
Practice Address - Street 1:14010 SMOKETOWN RD STE 117
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4704
Practice Address - Country:US
Practice Address - Phone:718-920-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003441363A00000X
NJ25MP00199700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant