Provider Demographics
NPI:1649422403
Name:TUTTLE, ALICIA THERIOT (PA)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:THERIOT
Last Name:TUTTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SKYLYN DR 240
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1069
Mailing Address - Country:US
Mailing Address - Phone:864-253-8100
Mailing Address - Fax:
Practice Address - Street 1:1071 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2201
Practice Address - Country:US
Practice Address - Phone:864-278-7088
Practice Address - Fax:864-278-7091
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200212363A00000X
SCPA 1746363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant