Provider Demographics
NPI:1407826589
Name:ANDERSON, DARCY JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:DARCY
Middle Name:JEAN
Last Name:ANDERSON
Suffix:
Gender:F
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 1:2570 24TH ST
Mailing Address - Street 2:SUITE 124
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5394
Mailing Address - Country:US
Mailing Address - Phone:309-779-3670
Mailing Address - Fax:309-779-3675
Practice Address - Street 1:2570 24TH ST
Practice Address - Street 2:SUITE 124
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5394
Practice Address - Country:US
Practice Address - Phone:309-779-3670
Practice Address - Fax:309-779-3675
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04485OtherMEDICARE IND. PROVIDER #
ILK04485OtherMEDICARE IND. PROVIDER #
IL200715047Medicare PIN