Provider Demographics
NPI:1932283512
Name:CLARK, LYNNE PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:PATRICIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
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
Practice Address - Country:US
Practice Address - Phone:253-752-8882
Practice Address - Fax:253-752-8907
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035921208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8871330Medicare PIN
F36862Medicare UPIN