Provider Demographics
NPI:1336205095
Name:TULLY, JEAN MARGARET (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARGARET
Last Name:TULLY
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Gender:F
Credentials:RPA-C
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Mailing Address - Street 1:1 STADIUM DR
Mailing Address - Street 2:STUDENT HEALTH SERVICE
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-3191
Mailing Address - Country:US
Mailing Address - Phone:631-632-6740
Mailing Address - Fax:
Practice Address - Street 1:1 STADIUM DR
Practice Address - Street 2:STUDENT HEALTH SERVICE
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3191
Practice Address - Country:US
Practice Address - Phone:631-632-6740
Practice Address - Fax:631-632-6936
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-10-08
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Provider Licenses
StateLicense IDTaxonomies
NY005514-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant