Provider Demographics
NPI:1003863432
Name:GILMAN, RANDAL KEITH (PA)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:KEITH
Last Name:GILMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:GILMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1288 KENDRA LN
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-9269
Mailing Address - Country:US
Mailing Address - Phone:909-931-3411
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4475
Practice Address - Fax:909-558-4143
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14703363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14703Medicaid
CAGR0058270Medicaid
CAGR0058271Medicaid
CAW11983Medicare PIN
CAGR0058271Medicaid
CAGR0058270Medicaid
CATP035Medicare PIN