Provider Demographics
NPI:1326109992
Name:DALTON, NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DALTON
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 1:2300 N EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2868
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:241 W WEAVER RD
Practice Address - Street 2:SUITE 145B
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9762
Practice Address - Country:US
Practice Address - Phone:217-794-5472
Practice Address - Fax:217-794-5458
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
833120OtherMEDICARE GROUP #
P00807365OtherRR INDIVIDUAL #
CA2264OtherRR GROUP #
833120014Medicare PIN