Provider Demographics
NPI:1326015074
Name:ILTIS, BEVERLY K (PA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:K
Last Name:ILTIS
Suffix:
Gender:F
Credentials:PA
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 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-757-6042
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:805 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5130
Practice Address - Country:US
Practice Address - Phone:903-757-6042
Practice Address - Fax:903-291-6138
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286521406Medicaid
TXTXB148868Medicare UPIN
TXS90110Medicare UPIN