Provider Demographics
NPI:1609464122
Name:OLLISON, GABRIEL LAMONT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:LAMONT
Last Name:OLLISON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:611 WILDERNESS TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-5006
Mailing Address - Country:US
Mailing Address - Phone:704-968-0766
Mailing Address - Fax:
Practice Address - Street 1:203 SALISBURY ST
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2155
Practice Address - Country:US
Practice Address - Phone:704-694-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant