Provider Demographics
NPI:1164421921
Name:GILLIS-BRAGG, PATRICIA (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:GILLIS-BRAGG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:GILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 E CARROLL ST
Mailing Address - Street 2:PRMC INPATIENT SERVICES
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-543-7536
Mailing Address - Fax:410-543-7272
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:PRMC INPATIENT SERVICES
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-543-7536
Practice Address - Fax:410-543-7272
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR075086363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1184832040OtherGROUP NPI
MD642802900Medicaid
S89974Medicare UPIN