Basic Information
| Provider Information | |||||||||
| NPI: | 1871089508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILLER | ||||||||
| FirstName: | MAKENZIE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2018 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2189 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 2189 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.