Basic Information
| Provider Information | |||||||||
| NPI: | 1538196134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 MADISON ST | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062648100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 S LAVENTURE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982746033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604242400 | ||||||||
| FaxNumber: | 3604242418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10004220 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA10004220 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0164819 | 01 | WA | L&I | OTHER | 263660 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8406258 | 05 | WA | MEDICAID |