Provider Demographics
NPI:1568479400
Name:CLARK, WAYNE S (ARNP)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:ARNP
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 9787
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98909-0787
Mailing Address - Country:US
Mailing Address - Phone:509-574-3353
Mailing Address - Fax:509-225-3163
Practice Address - Street 1:1460 N 16TH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7102
Practice Address - Country:US
Practice Address - Phone:509-574-3800
Practice Address - Fax:509-574-3806
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002529363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9607078Medicaid
WA0263471OtherL&I
WA0263471OtherL&I
WAG8892059Medicare PIN