Provider Demographics
NPI:1063747269
Name:NEILL, BRIAN SHANE (DOM)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:SHANE
Last Name:NEILL
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 FENCE POST TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1343
Mailing Address - Country:US
Mailing Address - Phone:740-602-3167
Mailing Address - Fax:
Practice Address - Street 1:2802 FLINTROCK TRCE
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-1743
Practice Address - Country:US
Practice Address - Phone:512-263-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH116171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist