Individual
BETHANY WILEY LILL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
720 TRANSIT AVE, SUITE 202, CANTON, GA 30114-2540
(770) 427-5717
(770) 514-6744
Mailing address
300 TOWER RD NE, SUITE 200, MARIETTA, GA 30060-9404
(770) 427-5717
(770) 514-6744
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
—
—
363AS0400X
Surgical Physician Assistant
Primary
006629
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20I2973206
MEDICARE PTAN
GA
Enumeration date
09/22/2012
Last updated
08/27/2014
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