MEDICARE: MR. JOHN MICHAEL NELLIGAN RPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	007811-1	NY

General Provider Information

NPI Number	:	1255420089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN MICHAEL NELLIGAN RPA

Provider Business Mailing Address
First Line	:	14 MOUNTAIN LEDGE
Second Line	:
City	:	GANSEVOORT
State	:	NY
Zip	:	12831-1858
Country	:	US
Telephone Number	:	518-584-4953
Fax Number	:	518-584-7916

Provider Business Practice Location Address
First Line	:	14 MOUNTAIN LEDGE
Second Line	:
City	:	GANSEVOORT
State	:	NY
Zip	:	12831-1858
Country	:	US
Telephone Number	:	518-584-4953
Fax Number	:	518-584-7916

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	09/20/2007

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