Healthcare Provider Details

I. General information

NPI: 1588153803
Provider Name (Legal Business Name): ANDREW CLAY KITTERMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

IV. Provider business mailing address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

V. Phone/Fax

Practice location:
  • Phone: 309-243-3000
  • Fax: 309-243-3040
Mailing address:
  • Phone: 309-243-3000
  • Fax: 309-243-3040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: