Basic Information
| Provider Information | |||||||||
| NPI: | 1568479400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9787 | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989090787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095743353 | ||||||||
| FaxNumber: | 5092253163 | ||||||||
| Practice Location | |||||||||
| Address1: | 1460 N 16TH AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989027102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095743800 | ||||||||
| FaxNumber: | 5095743806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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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 | 363L00000X | AP30002529 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 9607078 | 05 | WA | MEDICAID | 0263471 | 01 | WA | L&I | OTHER |