Provider Demographics
NPI:1104813997
Name:AYCOCK, SHARON (PA-C)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-655-7888
Mailing Address - Fax:309-655-7905
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-655-7888
Practice Address - Fax:309-655-7905
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P74489Medicare UPIN
IL211961Medicare ID - Type Unspecified