Provider Demographics
NPI:1427403369
Name:CLARY, MARK JUSTIN (LMP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JUSTIN
Last Name:CLARY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 W INSELS RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-9167
Mailing Address - Country:US
Mailing Address - Phone:360-951-9211
Mailing Address - Fax:
Practice Address - Street 1:8294 28TH CT NE STE 100
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-7140
Practice Address - Country:US
Practice Address - Phone:360-951-9211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60439284174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist