Provider Demographics
NPI:1235146960
Name:GILLIS, KATHERINE ANNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:ANNE
Last Name:GILLIS
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 1:508 LOBLOLLY DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-8723
Mailing Address - Country:US
Mailing Address - Phone:919-765-5957
Mailing Address - Fax:
Practice Address - Street 1:3480 WAKE FOREST RD
Practice Address - Street 2:SUITE 512
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7300
Practice Address - Country:US
Practice Address - Phone:919-862-5970
Practice Address - Fax:919-862-5975
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104096363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ26651Medicare UPIN
NC2761871Medicare PIN