Provider Demographics
NPI:1144288630
Name:JOHNSTONE, JILL M (PA)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:M
Last Name:JOHNSTONE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:A
Other - Last Name:MERLUZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5719 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1880
Mailing Address - Country:US
Mailing Address - Phone:315-251-3100
Mailing Address - Fax:315-449-9923
Practice Address - Street 1:4115 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 115
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6636
Practice Address - Country:US
Practice Address - Phone:315-329-7600
Practice Address - Fax:315-329-7608
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02565442Medicaid
P31266Medicare UPIN
NY02565442Medicaid