Healthcare Provider Details

I. General information

NPI: 1972077477
Provider Name (Legal Business Name): DALTON LEE SEXTON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10755 163RD PL
ORLAND PARK IL
60467-8861
US

IV. Provider business mailing address

4085 E 750 S
LEBANON IN
46052-9775
US

V. Phone/Fax

Practice location:
  • Phone: 812-243-3932
  • Fax:
Mailing address:
  • Phone: 812-243-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006920
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: