Provider Demographics
NPI:1659617561
Name:BARTELS, LARA B (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:B
Last Name:BARTELS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:B
Other - Last Name:SEELHOEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1001 HEATHER DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-2754
Practice Address - Country:US
Practice Address - Phone:217-586-8400
Practice Address - Fax:217-586-5093
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant