Provider Demographics
NPI:1225578107
Name:NEILL, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NEILL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093
Mailing Address - Country:US
Mailing Address - Phone:478-922-4281
Mailing Address - Fax:
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 309
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-479-3320
Practice Address - Fax:850-479-8789
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant