Provider Demographics
NPI:1851320196
Name:TILLEY, GARY L (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:TILLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-2151
Mailing Address - Country:US
Mailing Address - Phone:979-245-0626
Mailing Address - Fax:
Practice Address - Street 1:1115 AVENUE G
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-3540
Practice Address - Country:US
Practice Address - Phone:979-245-6783
Practice Address - Fax:979-241-6783
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX441807367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC-80BOtherBC-BS
TXC087543C5Medicaid
TXC-80Medicare ID - Type Unspecified87543C