Provider Demographics
NPI:1225023294
Name:AULD, DEBORAH L (PA-C)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:AULD
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 1:1245 S MILL ST
Mailing Address - Street 2:PO BOX 231
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-2004
Mailing Address - Country:US
Mailing Address - Phone:618-327-8119
Mailing Address - Fax:618-327-8141
Practice Address - Street 1:1245 S MILL ST
Practice Address - Street 2:POB 231
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-2004
Practice Address - Country:US
Practice Address - Phone:618-327-8119
Practice Address - Fax:618-327-8141
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP08135Medicare UPIN
ILK24157Medicare PIN
ILIL3374033Medicare PIN
ILK02100Medicare PIN