Provider Demographics
NPI:1831230911
Name:CLARK, NANCY L (PA-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:L
Other - Last Name:HEAVERLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13033 BELLEVUE REDMOND RD
Mailing Address - Street 2:#110
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2633
Mailing Address - Country:US
Mailing Address - Phone:425-468-6500
Mailing Address - Fax:425-468-6501
Practice Address - Street 1:13033 BELLEVUE REDMOND RD
Practice Address - Street 2:#110
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2633
Practice Address - Country:US
Practice Address - Phone:425-468-6500
Practice Address - Fax:425-468-6501
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003692363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA171527OtherLABOR AND INDUSTRIES
WAR40755Medicare UPIN