Provider Demographics
NPI:1174193312
Name:MCNEILL, MICAH WEBSTER (NP-C)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:WEBSTER
Last Name:MCNEILL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25140 INDIAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-8819
Mailing Address - Country:US
Mailing Address - Phone:815-973-9987
Mailing Address - Fax:
Practice Address - Street 1:25140 INDIAN RIDGE RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-8819
Practice Address - Country:US
Practice Address - Phone:815-973-9987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAWAITING363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily