1306849955 NPI number — MICHAEL J CLARK PT

Table of content: MICHAEL J CLARK PT (NPI 1306849955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306849955 NPI number — MICHAEL J CLARK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
MIKE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1306849955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 W TIETAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-4363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-522-0114
Provider Business Mailing Address Fax Number:
509-522-9868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W TIETAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-4363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-522-0114
Provider Business Practice Location Address Fax Number:
509-522-9868
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2569 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00005772 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 650011919 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0766690001 . This is a "CIGNA GOVERNMENT SERVICES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 108672 . This is a "LABOR & INDUSTRIES PROVID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8348476 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL5823 . This is a "REGENCE BC/BS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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