Provider Demographics
NPI:1548384811
Name:LYNNE P CLARK MD PS
Entity Type:Organization
Organization Name:LYNNE P CLARK MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-752-8882
Mailing Address - Street 1:6002 N WESTGATE BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2571
Mailing Address - Country:US
Mailing Address - Phone:253-752-8882
Mailing Address - Fax:253-752-8907
Practice Address - Street 1:6002 N WESTGATE BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2571
Practice Address - Country:US
Practice Address - Phone:253-752-8882
Practice Address - Fax:253-752-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035921208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB15172Medicare PIN
F36862Medicare UPIN