Provider Demographics
NPI:1235110859
Name:NEILL, JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NEILL
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 1:7323 MARBACH RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1907
Mailing Address - Country:US
Mailing Address - Phone:210-674-0257
Mailing Address - Fax:210-674-0619
Practice Address - Street 1:14610 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052
Practice Address - Country:US
Practice Address - Phone:830-709-0257
Practice Address - Fax:830-709-5808
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8198J7Medicare ID - Type Unspecified
TXS86485Medicare UPIN