Basic Information
| Provider Information | |||||||||
| NPI: | 1427684968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | AUBREY | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 POTTERY AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608955000 | ||||||||
| FaxNumber: | 3608955034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 POTTERY AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608955000 | ||||||||
| FaxNumber: | 3608955034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2020 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP61034799 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | AP61034799 | 01 | WA | ARNP LICENSE | OTHER |