Basic Information
| Provider Information | |||||||||
| NPI: | 1932847290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLMAN | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DNP NURSE ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3812 CHRISTOPHER DR | ||||||||
| Address2: | |||||||||
| City: | EAST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117301474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3478435118 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 ROUTE 25A STE 225 | ||||||||
| Address2: | |||||||||
| City: | ROCKY POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117788802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315031400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2022 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 735812 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.