Provider Demographics
NPI:1467640292
Name:GALE, CAROLYN JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:GALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:JEAN
Other - Last Name:SHADOIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:101 E MILLER RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1252
Mailing Address - Country:US
Mailing Address - Phone:815-625-4790
Mailing Address - Fax:
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:IL
Practice Address - Zip Code:61376
Practice Address - Country:US
Practice Address - Phone:815-379-2020
Practice Address - Fax:815-379-2018
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2224363A00000X
AK5541363AM0700X
IL085001195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001195Medicaid
AKRH177FQOtherFQHC FOR MEDICAL
COS55197Medicare UPIN
AKMH0156Medicaid
AK021819Medicare Oscar/Certification
AKK162666Medicare PIN