Healthcare Provider Details

I. General information

NPI: 1003741729
Provider Name (Legal Business Name): CONNOR REID CLARK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10511 19TH AVE SE STE B
EVERETT WA
98208-4279
US

IV. Provider business mailing address

2405 167TH PL SE
BOTHELL WA
98012-8002
US

V. Phone/Fax

Practice location:
  • Phone: 425-357-8885
  • Fax:
Mailing address:
  • Phone: 425-953-6326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT.PT.70108290
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: