Healthcare Provider Details

I. General information

NPI: 1508551458
Provider Name (Legal Business Name): CORAH L TILLERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 BEAM LN STE 300
FISHERSVILLE VA
22939-2350
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 434-297-9999
  • Fax: 434-297-9898
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0110009563
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110009563
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: