Provider Demographics
NPI:1770124026
Name:TILLEY, CALYSTA MEDLEY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CALYSTA
Middle Name:MEDLEY
Last Name:TILLEY
Suffix:
Gender:F
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 1:1409 E 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-4007
Mailing Address - Country:US
Mailing Address - Phone:912-548-9737
Mailing Address - Fax:
Practice Address - Street 1:600 COASTAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1973
Practice Address - Country:US
Practice Address - Phone:912-554-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant