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General NPI Number Information
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NPI Number | 1063475432
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Entity Type | Individual
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Provider Name | KEVIN CLARKE PA
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Gender | Male
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Dates
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Enumeration Date | 04/07/2006
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Last Update Date | 08/18/2020
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Provider Practice Location Address
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Address Line | 333 MADISON ST
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City | JOLIET
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State | IL
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Zip | 60435-8200
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Country | US
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Telephone | 815-725-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 HARGER RD STE 408
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City | OAK BROOK
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State | IL
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Zip | 60523-1818
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Country | US
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Telephone | 630-581-6522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085001326
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License Number State | IL
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