Provider Demographics
NPI:1306843685
Name:CLINKENBEARD, JOE (PA)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:CLINKENBEARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4252
Mailing Address - Fax:317-865-8318
Practice Address - Street 1:2421 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-6914
Practice Address - Country:US
Practice Address - Phone:219-462-6192
Practice Address - Fax:219-464-2585
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000721671OtherANTHEM TRADITIONAL
IN000000721671OtherANTHEM TRADITIONAL
INM400064137Medicare PIN