Provider Demographics
NPI:1750460481
Name:ANDERSON, CLARK (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:ANDERSON
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-0365
Mailing Address - Country:US
Mailing Address - Phone:309-672-4980
Mailing Address - Fax:309-671-2979
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 500A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:309-671-2979
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant