Healthcare Provider Details

I. General information

NPI: 1912453895
Provider Name (Legal Business Name): DAVID DYLAN PATE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FOUNDERS LN STE 100
JACKSONVILLE IL
62650-3924
US

IV. Provider business mailing address

15 FOUNDERS LN STE 100
JACKSONVILLE IL
62650-3924
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-0300
  • Fax: 217-862-0202
Mailing address:
  • Phone: 217-243-0300
  • Fax: 217-862-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085005952
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: