Provider Demographics
NPI:1598291163
Name:ILLSLEY, JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ILLSLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:ILLSLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:702 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4755
Mailing Address - Country:US
Mailing Address - Phone:561-350-0241
Mailing Address - Fax:
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4755
Practice Address - Country:US
Practice Address - Phone:336-599-9271
Practice Address - Fax:336-599-9271
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598291163Medicaid