Provider Demographics
NPI:1063451193
Name:CLARK, JEFFREY M (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 742997
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2997
Mailing Address - Country:US
Mailing Address - Phone:360-514-2142
Mailing Address - Fax:360-514-6820
Practice Address - Street 1:600 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3225
Practice Address - Country:US
Practice Address - Phone:360-514-2142
Practice Address - Fax:360-514-6820
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8357758Medicaid
WAG8855550Medicare PIN
WAS60890Medicare UPIN