Provider Demographics
NPI:1043303399
Name:DECKER, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FLANAGAN
Mailing Address - State:IL
Mailing Address - Zip Code:61740-7547
Mailing Address - Country:US
Mailing Address - Phone:815-796-4591
Mailing Address - Fax:815-796-4212
Practice Address - Street 1:103 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:FLANAGAN
Practice Address - State:IL
Practice Address - Zip Code:61740-7547
Practice Address - Country:US
Practice Address - Phone:815-796-4591
Practice Address - Fax:815-796-4212
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041275869/209004453363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA2182Medicare ID - Type UnspecifiedRR GROUP #
IL207991Medicare ID - Type UnspecifiedGROUP #
ILK04999Medicare ID - Type UnspecifiedINDIVIDUAL #
ILK36006Medicare ID - Type UnspecifiedINDIVIDUAL # - PONTIAC
P68085Medicare UPIN
IL202813Medicare ID - Type UnspecifiedINDIVIDUAL - PONTIAC
IL833230Medicare ID - Type UnspecifiedGROUP # - PONTIAC