Provider Demographics
NPI:1639600463
Name:O'NEILL, BRIAN JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOHN
Last Name:O'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 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE STE 200A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-323-2564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08345363A00000X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant