Provider Demographics
NPI:1134212343
Name:CLARK, LYN P (MD)
Entity type:Individual
Prefix:DR
First Name:LYN
Middle Name:P
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 1:2600 DENALI ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503
Mailing Address - Country:US
Mailing Address - Phone:907-222-4880
Mailing Address - Fax:907-272-4463
Practice Address - Street 1:2600 DENALI ST
Practice Address - Street 2:SUITE 302
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503
Practice Address - Country:US
Practice Address - Phone:907-222-4880
Practice Address - Fax:907-272-4463
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA1624208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1624Medicaid