Provider Demographics
NPI:1316298953
Name:LILL, BETHANY WILEY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:WILEY
Last Name:LILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TOWER RD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9404
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-514-6744
Practice Address - Street 1:720 TRANSIT AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2540
Practice Address - Country:US
Practice Address - Phone:770-427-5717
Practice Address - Fax:770-514-6744
Is Sole Proprietor?:No
Enumeration Date:2012-09-22
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA006629363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20I2973206OtherMEDICARE PTAN