Provider Demographics
NPI:1043818081
Name:TILLERY, SEAN AARON
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:AARON
Last Name:TILLERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 WAILUKU DR
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1218
Mailing Address - Country:US
Mailing Address - Phone:434-632-9653
Mailing Address - Fax:
Practice Address - Street 1:740 KILAUEA AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4234
Practice Address - Country:US
Practice Address - Phone:808-935-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-5076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist