Provider Demographics
NPI:1568463677
Name:RAY, DANITA J (PA-C)
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:J
Last Name:RAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:231 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IL
Practice Address - Zip Code:62694
Practice Address - Country:US
Practice Address - Phone:217-742-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00680379Medicare PIN
ILR00258Medicare PIN