Provider Demographics
NPI:1184133670
Name:ILLINIK, JEFFREY JOSEPH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:ILLINIK
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:JOSEPH
Other - Last Name:ILLINIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2060 GATOR BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8916
Mailing Address - Country:US
Mailing Address - Phone:757-763-4150
Mailing Address - Fax:
Practice Address - Street 1:2060 GATOR BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8916
Practice Address - Country:US
Practice Address - Phone:757-763-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant