Provider Demographics
NPI:1851717664
Name:TIELLEMAN, EMILY ANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ANNE
Last Name:TIELLEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:ANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:P.O. BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-648-7760
Mailing Address - Fax:214-648-7785
Practice Address - Street 1:5323 HARRY HINES BOULEVARD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-8898
Practice Address - Fax:214-645-8894
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA09189363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical