Basic Information
Provider Information | |||||||||
NPI: | 1932681764 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | VANESSA | ||||||||
MiddleName: | CHRISTINA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CASTOR | ||||||||
OtherFirstName: | VANESSA | ||||||||
OtherMiddleName: | CHRISITNA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1135 116TH AVE NE STE 500 | ||||||||
Address2: |   | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 980044627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256356560 | ||||||||
FaxNumber: | 4256373210 | ||||||||
Practice Location | |||||||||
Address1: | 1135 116TH AVE NE STE 500 | ||||||||
Address2: |   | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 980044627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256356560 | ||||||||
FaxNumber: | 4256373210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2018 | ||||||||
LastUpdateDate: | 01/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 61100713 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 085.006689 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 085.006689 | 01 | IL | PHYSICIAN ASSISTANT LICENSE | OTHER | 61100713 | 01 | WA | PHYSICIAN ASSISTANT LICENSE | OTHER | 1151434 | 01 |   | NCCPA | OTHER |