Provider Demographics
NPI:1083020648
Name:GILLIAM, LAUREN KRISTINA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:KRISTINA
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:KRISTINA
Other - Last Name:RAIKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4401 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-2744
Mailing Address - Country:US
Mailing Address - Phone:317-358-8060
Mailing Address - Fax:
Practice Address - Street 1:4401 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2744
Practice Address - Country:US
Practice Address - Phone:317-358-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant