Provider Demographics
NPI:1952496564
Name:MCKINNEY, DALE T (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:T
Last Name:MCKINNEY
Suffix:
Gender:M
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 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:1025 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-210-9662
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23639Medicare PIN
ILQ59639Medicare UPIN
IL208343011Medicare PIN
IL208352Medicare PIN