Provider Demographics
NPI:1760557920
Name:TILLER, KELLY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:TILLER
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 1:2100 STANTONSBURG ROAD
Mailing Address - Street 2:1 SOUTH ENT/ UROLOGY DEPT.
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3763
Mailing Address - Country:US
Mailing Address - Phone:252-847-2619
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG ROAD
Practice Address - Street 2:1 SOUTH ENT/ UROLOGY OFFICE
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-847-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006584363A00000X
NC100809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1274070001OtherDME MAC JURISDICTION C
P00407688OtherRAILROAD MEDICARE
R39735Medicare UPIN