Provider Demographics
NPI:1609075423
Name:GILLIARD, ELISABETH ANN (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ANN
Last Name:GILLIARD
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 S SR 15A # 100
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7817
Mailing Address - Country:US
Mailing Address - Phone:386-774-0016
Mailing Address - Fax:386-774-0606
Practice Address - Street 1:1590 S SR 15A # 100
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7817
Practice Address - Country:US
Practice Address - Phone:386-774-0016
Practice Address - Fax:386-774-0606
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical