Provider Demographics
NPI:1417069451
Name:CLARKE, RICHARD D (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:CLARKE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84571
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-5871
Mailing Address - Country:US
Mailing Address - Phone:425-353-3788
Mailing Address - Fax:425-353-8041
Practice Address - Street 1:400 S 3RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-2026
Practice Address - Country:US
Practice Address - Phone:425-353-3788
Practice Address - Fax:425-353-8041
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004891367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0153530OtherLABOR AND INDUSTRIES
WA9631946Medicaid
WA9631946Medicaid