MEDICARE: LORI YOUNG TILTON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	004326	GA
2	363A00000X	Physician Assistant	PA9107853	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306948179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI YOUNG TILTON PA-C

Provider Business Mailing Address
First Line	:	PO BOX 746638
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6638
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-376-4107

Provider Business Practice Location Address
First Line	:	220 S 14TH ST
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-3216
Country	:	US
Telephone Number	:	904-491-3688
Fax Number	:	904-390-7450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	01/30/2023

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