Provider Demographics
NPI:1497754386
Name:GILLIS, CAROL A (AA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:GILLIS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:A
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-475-8922
Mailing Address - Fax:
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8282
Practice Address - Fax:513-475-8283
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67000067367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2272713Medicaid
OHLE8223471Medicare ID - Type Unspecified