Basic Information
| Provider Information | |||||||||
| NPI: | 1215543756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLMAN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | ROSS | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284977576 | ||||||||
| FaxNumber: | 2284978869 | ||||||||
| Practice Location | |||||||||
| Address1: | 12330 ASHLEY DR | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395032737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288311572 | ||||||||
| FaxNumber: | 2288311218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 904708 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.