Provider Demographics
NPI:1952322117
Name:TILLERY, LEON (CRNAP)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:TILLERY
Suffix:
Gender:M
Credentials:CRNAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 TARLETON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-1550
Mailing Address - Country:US
Mailing Address - Phone:757-233-2874
Mailing Address - Fax:
Practice Address - Street 1:736 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4941
Practice Address - Country:US
Practice Address - Phone:757-312-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001080540367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAR36162Medicare UPIN
VA430001319Medicare ID - Type Unspecified