Provider Demographics
NPI:1811973597
Name:ALLISON, DARYL C (PAC)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:C
Last Name:ALLISON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:IA
Mailing Address - Zip Code:52342-2129
Mailing Address - Country:US
Mailing Address - Phone:641-484-2602
Mailing Address - Fax:641-484-6837
Practice Address - Street 1:401 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IA
Practice Address - Zip Code:52342-2129
Practice Address - Country:US
Practice Address - Phone:641-484-2602
Practice Address - Fax:641-484-6837
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAR94340Medicare UPIN
IAI10078Medicare ID - Type UnspecifiedMEDICARE PART B