Provider Demographics
NPI:1245601426
Name:DILLA, GWEN B
Entity Type:Individual
Prefix:MR
First Name:GWEN
Middle Name:B
Last Name:DILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 26299
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89126
Mailing Address - Country:US
Mailing Address - Phone:702-893-3333
Mailing Address - Fax:702-893-0960
Practice Address - Street 1:1815 E LAKE MEAD
Practice Address - Street 2:SUITE 103
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030
Practice Address - Country:US
Practice Address - Phone:702-839-0091
Practice Address - Fax:702-839-0095
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1702161Medicaid
NVGG318AMedicare PIN
NV1702161Medicaid