Provider Demographics
NPI:1194703488
Name:TILLOTSON, REBECCA (PA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:TILLOTSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-0008
Mailing Address - Country:US
Mailing Address - Phone:607-844-8181
Mailing Address - Fax:607-844-4288
Practice Address - Street 1:5 EVERGREEN ST.
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-0008
Practice Address - Country:US
Practice Address - Phone:607-844-8181
Practice Address - Fax:607-844-4288
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02181482Medicaid
NYS36235Medicare UPIN
NY02181482Medicaid