Provider Demographics
NPI:1811922982
Name:CLARK, JOHN P (PAC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:PAC
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Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:101 CAMELIA ST NW
Mailing Address - City:ROYAL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:99357
Mailing Address - Country:US
Mailing Address - Phone:509-346-1447
Mailing Address - Fax:509-346-1481
Practice Address - Street 1:101 CAMELIA ST NW
Practice Address - Street 2:
Practice Address - City:ROYAL CITY
Practice Address - State:WA
Practice Address - Zip Code:99357
Practice Address - Country:US
Practice Address - Phone:509-346-1447
Practice Address - Fax:509-346-1481
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10001599363AM0700X
CAPA11682363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical