Basic Information
| Provider Information | |||||||||
| NPI: | 1972069896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLIS | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4092 FOXWOOD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4092 FOXWOOD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574467420 | ||||||||
| FaxNumber: | 7574674173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2019 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110006573 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.