Provider Demographics
NPI:1912961897
Name:MERRELL, JOHN W (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MERRELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1032
Practice Address - Country:US
Practice Address - Phone:512-509-0200
Practice Address - Fax:512-218-6330
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10176363AS0400X
TNPA2181363AS0400X
TXPA13272363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625795Medicaid
LA56868P698Medicare PIN
LAS35207Medicare UPIN