Healthcare Provider Details

I. General information

NPI: 1093367104
Provider Name (Legal Business Name): SHARLINA D DHOM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHARLINA HERBOTH PA

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3610
  • Fax: 217-326-2704
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007048
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: