Provider Demographics
NPI:1578645537
Name:DESHON, DANA J
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:J
Last Name:DESHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 MAXINE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2498
Mailing Address - Country:US
Mailing Address - Phone:309-263-2424
Mailing Address - Fax:309-284-2255
Practice Address - Street 1:435 MAXINE DR
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2498
Practice Address - Country:US
Practice Address - Phone:309-263-2424
Practice Address - Fax:309-284-2255
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041270005/209000621363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840030OtherMEDICARE INDIVIDUAL PTAN
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
ILK37068Medicare ID - Type UnspecifiedINDIVIDUAL #
S83159Medicare UPIN
IL500007461Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL203444Medicare ID - Type UnspecifiedINDIVIDUAL #
IL809840Medicare ID - Type UnspecifiedGROUP #