Provider Demographics
NPI:1558399923
Name:GULLAGE, JOHN C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:GULLAGE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-9251
Mailing Address - Country:US
Mailing Address - Phone:417-533-6560
Mailing Address - Fax:
Practice Address - Street 1:331 HOSPITAL DR STE A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9251
Practice Address - Country:US
Practice Address - Phone:417-533-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002052363AS0400X
NE1999363AS0400X
MO2013029322363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO132300404OtherMEDICARE
WA000108957Medicare ID - Type Unspecified
MO132300404OtherMEDICARE