Provider Demographics
NPI:1295865533
Name:NIELL, JUDY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:MARIE
Last Name:NIELL
Suffix:
Gender:F
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:3203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-7727
Practice Address - Country:US
Practice Address - Phone:903-882-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-044OtherTRICARE
TXP01464137OtherRAIL ROAD MEDICARE
TX8660NNOtherBCBS
TX75-2616977-022OtherTRICARE
TX75-0818167-015OtherTRICARE
TXP01291627OtherRAIL ROAD MEDICARE
TX75-2616977-028OtherTRICARE
TX8287NDOtherBCBS
TX207269604Medicaid
TX207269605Medicaid
TX207269606Medicaid
TX75-0818167-048OtherTRICARE
TX75-1976930-005OtherTRICARE
TX75-2616977-002OtherTRICARE
TX8691NNOtherBCBS
TX207269603Medicaid
TX75-2616977-001OtherTRICARE
TX8284NDOtherBCBS
TX207269604Medicaid
LA5R968P362Medicare ID - Type Unspecified
TX403774YS6PMedicare PIN
TX75-2616977-001OtherTRICARE
TX75-0818167-044OtherTRICARE
TX207269606Medicaid
TX403776YS6VMedicare PIN