Provider Demographics
NPI:1073567079
Name:CLARK, WILLIAM R II
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:CLARK
Suffix:II
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 1:188 W NORTHERN LIGHTS BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3902
Mailing Address - Country:US
Mailing Address - Phone:907-276-2803
Mailing Address - Fax:907-278-8052
Practice Address - Street 1:188 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3902
Practice Address - Country:US
Practice Address - Phone:907-276-2803
Practice Address - Fax:907-278-8052
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61117110208800000X
AKAK1625208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1625Medicaid
AK034WCHVQAMedicare ID - Type Unspecified
AKMD1625Medicaid