Provider Demographics
NPI:1952623043
Name:NEILLY, CAROL RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:RAE
Last Name:NEILLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:RAE
Other - Last Name:STAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 CLARA BARTON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5738
Mailing Address - Country:US
Mailing Address - Phone:972-272-6561
Mailing Address - Fax:972-276-3067
Practice Address - Street 1:601 CLARA BARTON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5738
Practice Address - Country:US
Practice Address - Phone:972-272-6561
Practice Address - Fax:972-276-3067
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L26713Medicare PIN
TXP00941897Medicare PIN