Provider Demographics
NPI:1639399165
Name:NEILL, DAVID A (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:NEILL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 DANDRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-5963
Mailing Address - Country:US
Mailing Address - Phone:636-448-7042
Mailing Address - Fax:
Practice Address - Street 1:400 S WOODS MILL RD
Practice Address - Street 2:STE. 140
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3429
Practice Address - Country:US
Practice Address - Phone:314-485-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137173163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid