Provider Demographics
NPI:1851761027
Name:CLARKE, CALVIN
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:253-537-0293
Mailing Address - Fax:253-537-7650
Practice Address - Street 1:11019 CANYON RD E STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3001
Practice Address - Country:US
Practice Address - Phone:253-537-0293
Practice Address - Fax:253-537-7650
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60498791363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily