Provider Demographics
NPI:1740737444
Name:JOHN, JOLLY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JOLLY
Middle Name:ELIZABETH
Last Name:JOHN
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 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:STE 175
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:512-382-1933
Mailing Address - Fax:
Practice Address - Street 1:4515 SETON CENTER PKWY
Practice Address - Street 2:STE 175
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5290
Practice Address - Country:US
Practice Address - Phone:512-382-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-10
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant