Provider Demographics
NPI:1124682851
Name:NEILL, MARY ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:NEILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:LOFFHAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3366 OAKDALE AVE N STE 103
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2961
Mailing Address - Country:US
Mailing Address - Phone:763-520-7870
Mailing Address - Fax:763-520-7580
Practice Address - Street 1:3366 OAKDALE AVE N STE 103
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2961
Practice Address - Country:US
Practice Address - Phone:763-520-7870
Practice Address - Fax:763-520-7580
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant