Provider Demographics
NPI:1205479060
Name:NEVILLE, BRIAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:NEVILLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1893 ARDMORE DR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2005
Mailing Address - Country:US
Mailing Address - Phone:248-890-0740
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty