Kristen Gregory

 
 2019-10-01 04:45 PM 
 TO: 16103548946 FROM: 8313111968 
 Page: 90 
 Advanced Rx 
 360 Ortho and Spine 
 Stefan Prada, MD 
 Optimizing Provider Care鈩 
 DEA # BP3793696 
 11809 N Dale Mabry Hwy 
 Tampa, FL 33618 
 Patient Name: Kristen Gregory
 DOB: 1989-15-04 DOI: 2016-15-06
 Address: 1119 CR 457 Lake Danasoffhee FC 33538 
 ICD-10: HS4.2 

 Physician Signature: 
 RO, 
 Date: 2019-07-12
 (MM/DD/YYYY) 
 Patient Signature: Beverly Anderson 
 2021-03-04
 Date: 
 (MM/DD/YYYY) 
 www.Advanced-Rx.com I Phone 88813111 I Fax 92513111
 2430 Camino Ramon, Suite 120, San Ramon, CA 94549
