Provider Demographics
NPI:1144285289
Name:TILLMAN, ANTHONY L (PA)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:L
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:425 BMH PHYSICIANS OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5807
Practice Address - Country:US
Practice Address - Phone:865-980-5260
Practice Address - Fax:865-980-5261
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000828363A00000X
TNPA0828363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P35466Medicare UPIN
TN36644211Medicare PIN
970031028OtherRAILROAD MEDICARE
P35466Medicare UPIN