Provider Demographics
NPI:1689835720
Name:TALLMAN, JILL D (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:D
Last Name:TALLMAN
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-974-4466
Mailing Address - Fax:616-974-4582
Practice Address - Street 1:4069 LAKE DR SE
Practice Address - Street 2:SUITE 315
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-284-8950
Practice Address - Fax:616-284-8951
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN38550 108Medicare PIN