Provider Demographics
NPI:1275778805
Name:PALMER, MITCHELL CLARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:CLARK
Last Name:PALMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 W MEDICAL CENTER DR STE A200
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8437
Mailing Address - Country:US
Mailing Address - Phone:815-759-8070
Mailing Address - Fax:815-759-4931
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE A200
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8437
Practice Address - Country:US
Practice Address - Phone:815-759-8070
Practice Address - Fax:815-759-4931
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102913363AS0400X
IL085009855363A00000X
VA0110007847363A00000X
NHEL13328363A00000X
GAPA006322363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBU646ZMedicare PIN