Provider Demographics
NPI:1255801239
Name:TILLOTSON, WADE MARTIN (PT)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:MARTIN
Last Name:TILLOTSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 MONTEREY ST STE C102
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2954
Mailing Address - Country:US
Mailing Address - Phone:805-543-5100
Mailing Address - Fax:805-543-5106
Practice Address - Street 1:1422 MONTEREY ST STE C102
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2954
Practice Address - Country:US
Practice Address - Phone:805-543-5100
Practice Address - Fax:805-543-5106
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33508208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation