Healthcare Provider Details

I. General information

NPI: 1730444175
Provider Name (Legal Business Name): JOHN TILLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 06/01/2025
Certification Date: 06/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PACIFIC AVE
EVERETT WA
98201-4168
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-339-5430
  • Fax: 425-339-5454
Mailing address:
  • Phone: 206-860-5414
  • Fax: 206-720-8462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60652694
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA4432
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: