Provider Demographics
NPI:1083726459
Name:GILLIAM, DONNA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LYNN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-5129
Mailing Address - Country:US
Mailing Address - Phone:830-303-9400
Mailing Address - Fax:830-303-9420
Practice Address - Street 1:1761 HIGHWAY 46 W STE 104
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-4750
Practice Address - Country:US
Practice Address - Phone:830-608-1575
Practice Address - Fax:830-608-0868
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH0143584OtherDPS
TXPA03687OtherLICENSE
TX218278401Medicaid
TXMG1351294OtherDEA
TXPA03687OtherLICENSE