Healthcare Provider Details

I. General information

NPI: 1467640292
Provider Name (Legal Business Name): CAROLYN JEAN GALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN JEAN SHADOIN PA-C

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MAIN ST
WALNUT IL
61376
US

IV. Provider business mailing address

101 E MILLER RD
STERLING IL
61081-1252
US

V. Phone/Fax

Practice location:
  • Phone: 815-379-2020
  • Fax: 815-379-2018
Mailing address:
  • Phone: 815-625-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2224
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5541
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: