Provider Demographics
NPI:1306819750
Name:GILLIGAN, TRICIA (PA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:GILLIGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 N WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1131
Mailing Address - Country:US
Mailing Address - Phone:620-669-2500
Mailing Address - Fax:620-694-2076
Practice Address - Street 1:2101 N WALDRON ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1131
Practice Address - Country:US
Practice Address - Phone:620-669-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00946363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS042555Medicare ID - Type Unspecified
Q14050Medicare UPIN
KS2002252180AMedicare ID - Type Unspecified