Provider Demographics
NPI:1619374246
Name:TULLIS, PATRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:TULLIS
Suffix:
Gender:M
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 1:800 ROSE ST # MN150
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0293
Mailing Address - Country:US
Mailing Address - Phone:618-841-6282
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST # MN150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC337363AM0700X
KYPA1954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical