Provider Demographics
NPI:1821147539
Name:ACKERMAN, DAWN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:LEE
Last Name:ACKERMAN
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 1:400 KIRK DR
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1612
Mailing Address - Country:US
Mailing Address - Phone:269-655-4084
Mailing Address - Fax:
Practice Address - Street 1:3131 N WATER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2472
Practice Address - Country:US
Practice Address - Phone:217-876-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003061363A00000X
IL085003646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00325Medicare UPIN