Provider Demographics
NPI:1992964563
Name:TULLY, JOHN PATRICK (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PATRICK
Last Name:TULLY
Suffix:
Gender:M
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:PO BOX 6048
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6048
Mailing Address - Country:US
Mailing Address - Phone:541-382-4900
Mailing Address - Fax:541-706-2398
Practice Address - Street 1:1501 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6051
Practice Address - Country:US
Practice Address - Phone:541-382-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-08
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORP175245363A00000X
UT5008334-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500696906Medicaid
OR500696906Medicaid
ORR189987Medicare PIN