Provider Demographics
NPI:1902308075
Name:AUTTAPIBARN, CLINT
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:
Last Name:AUTTAPIBARN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 CLIFFSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-8405
Mailing Address - Country:US
Mailing Address - Phone:503-412-8557
Mailing Address - Fax:
Practice Address - Street 1:740 W ALLUVIAL AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5509
Practice Address - Country:US
Practice Address - Phone:800-797-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013809183500000X
WAPH60409983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist