Provider Demographics
NPI:1316228828
Name:DUKES, JASON LEE (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:DUKES
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:DEPT 960347
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0001
Mailing Address - Country:US
Mailing Address - Phone:800-684-0062
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0002
Practice Address - Country:US
Practice Address - Phone:309-672-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00988299OtherRRMCARE THRU CES
IL210426013Medicare PIN