Provider Demographics
NPI:1053481432
Name:CLANCY, MICHAEL A
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:CLANCY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 GEORGIANA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3511
Mailing Address - Country:US
Mailing Address - Phone:360-457-8534
Mailing Address - Fax:360-457-9741
Practice Address - Street 1:835 GEORGIANA ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3511
Practice Address - Country:US
Practice Address - Phone:360-457-8534
Practice Address - Fax:360-457-9741
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1002898Medicaid
WAG000500030Medicare ID - Type Unspecified
WA1002898Medicaid