Provider Demographics
NPI:1811485956
Name:DISMUKE, DASMYN L (PA)
Entity type:Individual
Prefix:
First Name:DASMYN
Middle Name:L
Last Name:DISMUKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DASMYN
Other - Middle Name:L
Other - Last Name:LANGSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1739
Practice Address - Country:US
Practice Address - Phone:833-724-8326
Practice Address - Fax:260-425-6845
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002439A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant