MEDICARE: DESHAUNA TILLMAN

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	3747P1801X	Personal Care Attendant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2600132498	OTHER	NV	NV DRIVER LICENSE CARD

General Provider Information

NPI Number	:	1912615303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESHAUNA TILLMAN

Provider Business Mailing Address
First Line	:	3509 PIONEER CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-2143
Country	:	US
Telephone Number	:	702-204-7938
Fax Number	:

Provider Business Practice Location Address
First Line	:	3509 PIONEER CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-2143
Country	:	US
Telephone Number	:	702-204-7938
Fax Number	:

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

Provider Enumeration Date	:	11/14/2022
Last Update Date	:	11/14/2022

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Directions to “ DESHAUNA TILLMAN ” Practice Location

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