Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 60704 | MN |
Y | 207X00000X | Orthopaedic Surgeon | MD61156092 | WA |
N | 207XS0117X | Orthopaedic Spine Surgeon | MD61156092 | WA |
NPI | 1407235724 |
---|---|
Provider Name | Dr. Nicholas Clark |
First Address | Renton, WA 98055-5791 |
Second Address | Renton, WA 98055-5791 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2015 |
Last Update Date | 19/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
440706 | WA LABOR & INDUSTRIES (01) | WA |