Provider Demographics
NPI:1528041951
Name:GILLUM, IRA RICHARD (PA C)
Entity Type:Individual
Prefix:MR
First Name:IRA
Middle Name:RICHARD
Last Name:GILLUM
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:104 S DEVINE
Mailing Address - City:GROVETON
Mailing Address - State:TX
Mailing Address - Zip Code:75845-0459
Mailing Address - Country:US
Mailing Address - Phone:936-642-0841
Mailing Address - Fax:936-642-0849
Practice Address - Street 1:104 S DEVINE
Practice Address - Street 2:
Practice Address - City:GROVETON
Practice Address - State:TX
Practice Address - Zip Code:75845-0104
Practice Address - Country:US
Practice Address - Phone:936-642-0841
Practice Address - Fax:936-642-0849
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 00013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA 00013OtherLICENSE
TXPA 00013OtherLICENSE