Provider Demographics
NPI:1619903721
Name:TILMON, JOHN BANKS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BANKS
Last Name:TILMON
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 1:1315 STUBBS VINSON RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8553
Mailing Address - Country:US
Mailing Address - Phone:318-343-2483
Mailing Address - Fax:
Practice Address - Street 1:10374 HIGHWAY 165 N STE B
Practice Address - Street 2:
Practice Address - City:STERLINGTON
Practice Address - State:LA
Practice Address - Zip Code:71280-3320
Practice Address - Country:US
Practice Address - Phone:318-665-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10255RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625094Medicaid