Healthcare Provider Details

I. General information

NPI: 1710979521
Provider Name (Legal Business Name): ERIC M TILLEY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 134TH ST SW STE 120 RADIA INC., PS
EVERETT WA
98204-5322
US

IV. Provider business mailing address

728 134TH ST SW STE 120
EVERETT WA
98204-5322
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-7671
  • Fax:
Mailing address:
  • Phone: 425-640-7671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10005032
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: