Provider Demographics
NPI:1093804866
Name:LILLIS, THOMAS (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LILLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CATHARINE ST
Mailing Address - Street 2:P.O. BOX 550
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3100
Mailing Address - Country:US
Mailing Address - Phone:866-868-8417
Mailing Address - Fax:845-790-2675
Practice Address - Street 1:127 S BROADWAY
Practice Address - Street 2:ST. JOSEPHS MEDICAL CENTER
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-4006
Practice Address - Country:US
Practice Address - Phone:914-378-7000
Practice Address - Fax:845-790-2675
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY432918-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR5A001Medicare PIN
NYG400001484Medicare PIN