Provider Demographics
NPI:1487758892
Name:DOSS, CARMELLA JO (PA)
Entity type:Individual
Prefix:
First Name:CARMELLA
Middle Name:JO
Last Name:DOSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARMELLA
Other - Middle Name:JO
Other - Last Name:BORUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:
Practice Address - Street 1:14410 ROUTE 37
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-3166
Practice Address - Country:US
Practice Address - Phone:618-983-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP80156Medicare UPIN