Provider Demographics
NPI:1902900020
Name:CONKLIN, DARYL GENE (PAC)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:GENE
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 WILLAIMS AVE
Mailing Address - Street 2:PO BOX 508
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564-0508
Mailing Address - Country:US
Mailing Address - Phone:360-983-3069
Mailing Address - Fax:360-983-3098
Practice Address - Street 1:108 KINDLE RD
Practice Address - Street 2:
Practice Address - City:RANDLE
Practice Address - State:WA
Practice Address - Zip Code:98377-1411
Practice Address - Country:US
Practice Address - Phone:360-497-3333
Practice Address - Fax:360-497-5073
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8374738Medicaid
WA1100687OtherCOMMUNITY HEALTH
WACO3874OtherREGENCE RIDER
WA1100687OtherCOMMUNITY HEALTH