Provider Demographics
NPI:1598767055
Name:ALSUP, TOLLY B (PA-C)
Entity Type:Individual
Prefix:
First Name:TOLLY
Middle Name:B
Last Name:ALSUP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 PARISA DR.
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003
Mailing Address - Country:US
Mailing Address - Phone:270-444-8477
Mailing Address - Fax:270-444-8479
Practice Address - Street 1:3101 PARISA DR.
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-444-8477
Practice Address - Fax:270-444-8479
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1898363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPO1321Medicare UPIN