Provider Demographics
NPI:1467502286
Name:TILLEY, CHARLES R JR
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:TILLEY
Suffix:JR
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-0070
Mailing Address - Country:US
Mailing Address - Phone:712-546-4624
Mailing Address - Fax:712-546-9395
Practice Address - Street 1:180 10TH ST SE STE 201
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2557
Practice Address - Country:US
Practice Address - Phone:712-546-4624
Practice Address - Fax:712-546-9395
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1409363A00000X
IA001775363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI19477Medicare PIN
Q76209Medicare UPIN