Provider Demographics
NPI:1992762116
Name:LAKATOS, DANA (PA-C)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:LAKATOS
Suffix:
Gender:M
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 1:1300 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1048
Mailing Address - Country:US
Mailing Address - Phone:618-443-1337
Mailing Address - Fax:618-443-1383
Practice Address - Street 1:1300 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1048
Practice Address - Country:US
Practice Address - Phone:618-443-1337
Practice Address - Fax:618-443-1383
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL08500046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR18818Medicare UPIN