Provider Demographics
NPI:1215543756
Name:TILLMAN, JUSTIN ROSS (FNP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROSS
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:12330 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2737
Practice Address - Country:US
Practice Address - Phone:228-831-1572
Practice Address - Fax:228-831-1218
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS904708363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily