Provider Demographics
NPI:1972213148
Name:TULLOH, BRIAN CLANCY (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CLANCY
Last Name:TULLOH
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 1:265 WESTERN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2458
Mailing Address - Country:US
Mailing Address - Phone:207-661-0200
Mailing Address - Fax:207-661-0299
Practice Address - Street 1:265 WESTERN AVE STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2458
Practice Address - Country:US
Practice Address - Phone:207-661-0200
Practice Address - Fax:207-661-0299
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2930363A00000X
NH2961363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant