Provider Demographics
NPI:1205820917
Name:CLARK, BARBARA JB (MPAS PAC)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:JB
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPAS PAC
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:J
Other - Last Name:BOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:STE 402
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-343-5117
Mailing Address - Fax:309-343-0029
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:STE 402
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-343-5117
Practice Address - Fax:309-343-0029
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S58306Medicare UPIN
ILK18592Medicare ID - Type Unspecified