Provider Demographics
NPI:1417306077
Name:CLARK, ASHLEY (PA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 JOHN ST APT 421
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5273
Mailing Address - Country:US
Mailing Address - Phone:607-437-6542
Mailing Address - Fax:
Practice Address - Street 1:825 EASTLAKE AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4405
Practice Address - Country:US
Practice Address - Phone:206-288-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60672205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417306077Medicaid