Provider Demographics
NPI:1093847600
Name:DESUTTER, JULIE A (PA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:DESUTTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-676-8123
Practice Address - Fax:309-676-8455
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001405363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00016083OtherRAILROAD MEDICARE
ILP47115Medicare UPIN
ILK20215Medicare PIN