Provider Demographics
NPI:1679721179
Name:BOHN, ELIZABETH ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:BOHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2630 HIGHWAY K STE 100
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6624
Mailing Address - Country:US
Mailing Address - Phone:636-240-5454
Mailing Address - Fax:
Practice Address - Street 1:2630 HIGHWAY K STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-6624
Practice Address - Country:US
Practice Address - Phone:636-240-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022029696363A00000X
IL085003294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10019630OtherBLUE CROSS BLUE SHIELD
IL115574OtherHEALTHLINK
IL033352OtherHEALTH ALLIANCE
IL143870OtherMEDICARE RAILROAD
IL036067104Medicaid
IL115574OtherHEALTHLINK
IL214881Medicare Oscar/Certification