Provider Demographics
NPI:1225098494
Name:GILLEN, KENNETH R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:GILLEN
Suffix:
Gender:M
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 1:5900 N LIBBY RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-4215
Mailing Address - Country:US
Mailing Address - Phone:530-872-5191
Mailing Address - Fax:
Practice Address - Street 1:277 COHASSET RD
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2242
Practice Address - Country:US
Practice Address - Phone:530-872-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP99D17Medicare UPIN