Provider Demographics
NPI:1275116477
Name:CLARK, NATHAN SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:SCOTT
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 QUAIL DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5504
Mailing Address - Country:US
Mailing Address - Phone:206-650-1999
Mailing Address - Fax:
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-493-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program