Provider Demographics
NPI:1407970395
Name:VAN BEVERN, PAMELA ANN (PA-C, MPAS)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:ANN
Last Name:VAN BEVERN
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:STE. 160
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5368
Mailing Address - Country:US
Mailing Address - Phone:618-235-0460
Mailing Address - Fax:618-235-1464
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:STE. 160
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5368
Practice Address - Country:US
Practice Address - Phone:618-235-0460
Practice Address - Fax:618-235-1464
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85000407363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3374020Medicare PIN