Provider Demographics
NPI:1861949950
Name:MONTICCIOLO, JILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MONTICCIOLO
Suffix:
Gender:F
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 1:2405 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5961
Mailing Address - Country:US
Mailing Address - Phone:586-264-1800
Mailing Address - Fax:586-264-1155
Practice Address - Street 1:2405 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5961
Practice Address - Country:US
Practice Address - Phone:586-264-1800
Practice Address - Fax:586-264-1155
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant