Basic Information
| Provider Information | |||||||||
| NPI: | 1225576820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOTZBACH | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | BAKER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 54TH ST | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395074602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288062288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2819 DENNY AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288189620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00315 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.