Provider Demographics
NPI:1639560907
Name:LILLEY, THOMAS JOSHUA (MPAM, MED, PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOSHUA
Last Name:LILLEY
Suffix:
Gender:M
Credentials:MPAM, MED, PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 KINGS PARK DRIVE EXT APT A
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2737
Mailing Address - Country:US
Mailing Address - Phone:717-926-5532
Mailing Address - Fax:
Practice Address - Street 1:7374 OSWEGO ROAD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3717
Practice Address - Country:US
Practice Address - Phone:717-926-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260018262255A2300X
VA0110008846363A00000X
NY029349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer