Basic Information
| Provider Information | |||||||||
| NPI: | 1700451499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLER | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437569292 | ||||||||
| FaxNumber: | 8437569260 | ||||||||
| Practice Location | |||||||||
| Address1: | 3109 CASEY ST | ||||||||
| Address2: | |||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295692807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437569292 | ||||||||
| FaxNumber: | 8437569260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2021 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3826 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 4646PA | 05 | SC | MEDICAID |