Healthcare Provider Details

I. General information

NPI: 1790972644
Provider Name (Legal Business Name): JOHN GERARD LILLO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN GERARD LILLO PAC

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOBO CANYON RD WESTERN NEW MEXICO CORRECTIONS
GRANTS NM
87020-0250
US

IV. Provider business mailing address

PO BOX 250
GRANTS NM
87020-0250
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-8360
  • Fax: 505-876-8357
Mailing address:
  • Phone: 505-876-8360
  • Fax: 505-876-8357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number94PA31
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: