Basic Information
| Provider Information | |||||||||
| NPI: | 1508038043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANCILLER | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR DEPT 6008 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622821419 | ||||||||
| FaxNumber: | 5629204642 | ||||||||
| Practice Location | |||||||||
| Address1: | 10234 ROSECRANS AVE | ||||||||
| Address2: | |||||||||
| City: | BELLFLOWER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907062602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629201692 | ||||||||
| FaxNumber: | 5629204643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 17751 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 17751 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.