Provider Demographics
NPI:1598947111
Name:GILLAM, SARA LINDSAY (PA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LINDSAY
Last Name:GILLAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 TELESTAR CT STE 300
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1263
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:2901 TELESTAR CT STE 100
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1261
Practice Address - Country:US
Practice Address - Phone:703-208-9797
Practice Address - Fax:703-591-0829
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003485363AM0700X
VA0110003987363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1598947111Medicaid
VA1598947111Medicaid
DC344903ZC3UMedicare PIN