Provider Demographics
NPI:1447409446
Name:CLARK, HOLLY HEIST MESKIMEN (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:HEIST MESKIMEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:HEIST
Other - Last Name:MESKIMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:WA
Mailing Address - Zip Code:98932
Mailing Address - Country:US
Mailing Address - Phone:509-865-6450
Mailing Address - Fax:509-854-1919
Practice Address - Street 1:115 SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:WA
Practice Address - Zip Code:98932
Practice Address - Country:US
Practice Address - Phone:509-865-6450
Practice Address - Fax:509-854-1919
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60726169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19897Medicaid
CAAR072ZMedicare PIN