Provider Demographics
NPI:1487867321
Name:GILLIS, DAVID ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
Last Name:GILLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15350 W NATIONAL AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5158
Mailing Address - Country:US
Mailing Address - Phone:262-227-8541
Mailing Address - Fax:414-755-1481
Practice Address - Street 1:15350 W NATIONAL AVE STE 102-219
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5158
Practice Address - Country:US
Practice Address - Phone:262-227-8541
Practice Address - Fax:414-755-1481
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4429024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist