Provider Demographics
NPI:1790243293
Name:ELLIOTT, BILLY MERRILL III
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:MERRILL
Last Name:ELLIOTT
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11692 TANAGER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2570
Mailing Address - Country:US
Mailing Address - Phone:904-654-8294
Mailing Address - Fax:
Practice Address - Street 1:3625 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4207
Practice Address - Country:US
Practice Address - Phone:904-702-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL525082146L00000X
FL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic