Provider Demographics
NPI:1730173899
Name:CLARK, MERIDITH JILL (PA)
Entity type:Individual
Prefix:
First Name:MERIDITH
Middle Name:JILL
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MERIDITH
Other - Middle Name:
Other - Last Name:BABCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1180 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-5603
Mailing Address - Country:US
Mailing Address - Phone:727-943-3111
Mailing Address - Fax:727-943-3334
Practice Address - Street 1:43309 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-6221
Practice Address - Country:US
Practice Address - Phone:727-943-3111
Practice Address - Fax:727-943-3334
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00210547OtherMEDICARE RR
FLP00210547OtherMEDICARE RR
FLU3034YMedicare PIN