Provider Demographics
NPI:1942276282
Name:CLARK, LISA DIANE (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1800
Mailing Address - Country:US
Mailing Address - Phone:503-274-4885
Mailing Address - Fax:503-274-4814
Practice Address - Street 1:265 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1800
Practice Address - Country:US
Practice Address - Phone:503-274-4885
Practice Address - Fax:503-274-4814
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273968Medicaid
WA1022791Medicaid
ORQ62925Medicare UPIN
WA1022791Medicaid
OR273968Medicaid