Provider Demographics
NPI:1306800396
Name:EUBANKS, ANGIE M (PAC)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:M
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5383 STATE ROUTE 154
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-3342
Mailing Address - Country:US
Mailing Address - Phone:618-357-2131
Mailing Address - Fax:618-357-8844
Practice Address - Street 1:5383 STATE ROUTE 154
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-3342
Practice Address - Country:US
Practice Address - Phone:618-357-2131
Practice Address - Fax:618-357-8844
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL342557OtherHEALTHLINK
IL970020589OtherMEDICARE RAILROAD
IL07320380OtherBCBS
IL376006955007Medicaid
IL376006955007Medicaid
IL970020589OtherMEDICARE RAILROAD