Provider Demographics
NPI:1033550926
Name:GILLMAN, STEPHANIE CATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CATHERINE
Last Name:GILLMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:CATHERINE
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:4200 WHITEHALL DR
Practice Address - Street 2:SUITE 130
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9694
Practice Address - Country:US
Practice Address - Phone:734-995-0425
Practice Address - Fax:734-995-0303
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05126363AM0700X
MI5601008137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580505Medicaid
MD926580501Medicaid
MD926580502Medicaid
MD926580502Medicaid
MD926580501Medicaid
MD333786ZCSVMedicare PIN