Provider Demographics
NPI:1336974476
Name:REA, DALTON
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:REA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 N STERLING AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1837
Mailing Address - Country:US
Mailing Address - Phone:309-687-5900
Mailing Address - Fax:
Practice Address - Street 1:3335 N STERLING AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1837
Practice Address - Country:US
Practice Address - Phone:309-687-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085010753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant