Provider Demographics
NPI:1417620618
Name:GILLIES, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GILLIES
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 1:2724 BASTION DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-7177
Mailing Address - Country:US
Mailing Address - Phone:435-668-9413
Mailing Address - Fax:
Practice Address - Street 1:1174 N 22ND ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5401
Practice Address - Country:US
Practice Address - Phone:307-766-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY50974363LF0000X
WY40289163WP2201X
WY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program