Healthcare Provider Details

I. General information

NPI: 1255420089
Provider Name (Legal Business Name): JOHN MICHAEL NELLIGAN RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MOUNTAIN LEDGE
GANSEVOORT NY
12831-1858
US

IV. Provider business mailing address

14 MOUNTAIN LEDGE
GANSEVOORT NY
12831-1858
US

V. Phone/Fax

Practice location:
  • Phone: 518-584-4953
  • Fax: 518-584-7916
Mailing address:
  • Phone: 518-584-4953
  • Fax: 518-584-7916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007811-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: