Individual
JOHN ILLSLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
702 N MAIN ST, ROXBORO, NC 27573-4755
(336) 599-9271
(336) 599-9271
Mailing address
702 N MAIN ST, ROXBORO, NC 27573-4755
(561) 350-0241
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0010-07223
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1598291163
—
NC
Enumeration date
05/02/2017
Last updated
06/18/2020
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