Provider Demographics
NPI:1114003076
Name:GILLUM, SCOTT R (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:GILLUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7925 YOUREE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5127
Mailing Address - Country:US
Mailing Address - Phone:318-212-3610
Mailing Address - Fax:318-212-3672
Practice Address - Street 1:7925 YOUREE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5127
Practice Address - Country:US
Practice Address - Phone:318-212-3610
Practice Address - Fax:318-212-3672
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAPA200106363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAQ73732Medicare UPIN
LA5B103P793Medicare PIN
LA56770P792Medicare PIN
LA5B103Medicare PIN