Provider Demographics
NPI:1225066608
Name:MCCORMICK, DENA L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DENA
Middle Name:L
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DENA
Other - Middle Name:L
Other - Last Name:PANKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-942-2171
Practice Address - Fax:618-988-6186
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002236363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7210895OtherAETNA
IL3932056OtherBCBS
IL036062597Medicaid
IL894228OtherHEALTHLINK
IL10019630OtherBLUE CROSS
IL139759OtherHAMP
IL3932056OtherBCBS
IL214881Medicare PIN
IL10019630OtherBLUE CROSS
IL7210895OtherAETNA
IL036062597Medicaid
IL336570Medicare PIN