Provider Demographics
NPI:1790972644
Name:LILLO, JOHN GERARD (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GERARD
Last Name:LILLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:GERARD
Other - Last Name:LILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-0250
Mailing Address - Country:US
Mailing Address - Phone:505-876-8360
Mailing Address - Fax:505-876-8357
Practice Address - Street 1:LOBO CANYON RD
Practice Address - Street 2:WESTERN NEW MEXICO CORRECTIONS
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-0250
Practice Address - Country:US
Practice Address - Phone:505-876-8360
Practice Address - Fax:505-876-8357
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94PA31363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant