Provider Demographics
NPI:1710979521
Name:TILLEY, ERIC M (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:TILLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 134TH ST SW STE 120
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-5322
Mailing Address - Country:US
Mailing Address - Phone:425-640-7671
Mailing Address - Fax:
Practice Address - Street 1:728 134TH ST SW STE 120
Practice Address - Street 2:RADIA INC., PS
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-5322
Practice Address - Country:US
Practice Address - Phone:425-640-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10005032363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8924472Medicare PIN
WAG8924469Medicare PIN
WAG8924470Medicare PIN
MAQ41083Medicare UPIN
MAAP2391Medicare ID - Type Unspecified
WAG8924471Medicare PIN
WAG8924468Medicare PIN