Provider Demographics
NPI:1508805920
Name:GILLETTE, DIRK (PA)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1287 BURNS WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3109
Mailing Address - Country:US
Mailing Address - Phone:406-752-8120
Mailing Address - Fax:406-752-8134
Practice Address - Street 1:1287 BURNS WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3109
Practice Address - Country:US
Practice Address - Phone:406-752-8120
Practice Address - Fax:406-752-8134
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053124OtherNCCPA
MT1508805920OtherBCBS
MT1508805920Medicaid
1053124OtherNCCPA