Provider Demographics
NPI:1508038043
Name:CANCILLER, JOHNNY C (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:C
Last Name:CANCILLER
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 1:75 REMITTANCE DR DEPT 6008
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:10234 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2602
Practice Address - Country:US
Practice Address - Phone:562-920-1692
Practice Address - Fax:562-920-4643
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17751363A00000X
CA17751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant