Provider Demographics
NPI:1124153317
Name:O'NEILL, JOHN C (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:O'NEILL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5115
Mailing Address - Country:US
Mailing Address - Phone:360-923-7000
Mailing Address - Fax:
Practice Address - Street 1:700 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5115
Practice Address - Country:US
Practice Address - Phone:360-923-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003529363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8414047Medicaid
WA8414047Medicaid
WAGAB16323Medicare PIN
WAGAB16322Medicare PIN
WAGAB16324Medicare PIN
WAGAB16321Medicare PIN
WAG8872492Medicare PIN
WAGAB16325Medicare PIN