Provider Demographics
NPI:1932681764
Name:CLARK, VANESSA CHRISTINA (PA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:CHRISTINA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:CHRISITNA
Other - Last Name:CASTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1135 116TH AVE NE STE 500
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4627
Mailing Address - Country:US
Mailing Address - Phone:425-635-6560
Mailing Address - Fax:425-637-3210
Practice Address - Street 1:1135 116TH AVE NE STE 500
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4627
Practice Address - Country:US
Practice Address - Phone:425-635-6560
Practice Address - Fax:425-637-3210
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61100713363A00000X
IL085.006689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.006689OtherPHYSICIAN ASSISTANT LICENSE
WA61100713OtherPHYSICIAN ASSISTANT LICENSE
1151434OtherNCCPA