Healthcare Provider Details

I. General information

NPI: 1275778805
Provider Name (Legal Business Name): MITCHELL CLARK PALMER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

IV. Provider business mailing address

4309 W MEDICAL CENTER DR STE A200
MCHENRY IL
60050-8437
US

V. Phone/Fax

Practice location:
  • Phone: 815-759-8070
  • Fax: 815-759-4931
Mailing address:
  • Phone: 815-759-8070
  • Fax: 815-759-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9102913
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009855
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007847
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberEL13328
License Number StateNH
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA006322
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: