MEDICARE: MS. PATRICIA SUE TILLACK ANP

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	363LA2200X	Adult Health Nurse Practitioner	186	AZ

General Provider Information

NPI Number	:	1861459042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA SUE TILLACK ANP

Provider Business Mailing Address
First Line	:	9224 N 28TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-4705
Country	:	US
Telephone Number	:	602-510-6977
Fax Number	:	602-795-1442

Provider Business Practice Location Address
First Line	:	9224 N 28TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-4705
Country	:	US
Telephone Number	:	602-510-6977
Fax Number	:	602-795-1442

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

Provider Enumeration Date	:	04/29/2006
Last Update Date	:	07/08/2007

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