Provider Demographics
NPI:1043943459
Name:TILLMAN, MCKAY (FNP-C)
Entity Type:Individual
Prefix:
First Name:MCKAY
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:PEACHLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28133-0210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1212 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4318
Practice Address - Country:US
Practice Address - Phone:704-283-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC825286393Medicaid