Individual
BEVERLY K ILTIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
805 MEDICAL DR, LONGVIEW, TX 75605-5130
(903) 757-6042
(903) 291-6138
Mailing address
PO BOX 610393, DALLAS, TX 75261-0393
(903) 757-6042
(903) 237-1810
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA02521
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
286521406
—
TX
Enumeration date
03/01/2006
Last updated
11/11/2021
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