Healthcare Provider Details

I. General information

NPI: 1659462448
Provider Name (Legal Business Name): GARY DON CLINE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S SUITE 500
RENTON WA
98055-5773
US

IV. Provider business mailing address

4011 TALBOT RD S SUITE 500
RENTON WA
98055-5773
US

V. Phone/Fax

Practice location:
  • Phone: 425-251-5110
  • Fax: 425-793-7376
Mailing address:
  • Phone: 425-251-5110
  • Fax: 425-793-7376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberPA10002668
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberPA506
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10002668
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: