Provider Demographics
NPI:1619989530
Name:MCGILLIS, TRICIA ANN (PA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:ANN
Last Name:MCGILLIS
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:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-0087
Mailing Address - Country:US
Mailing Address - Phone:231-775-6076
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:100 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MI
Practice Address - Zip Code:49665
Practice Address - Country:US
Practice Address - Phone:231-743-0150
Practice Address - Fax:231-743-0152
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P36050-002Medicare ID - Type Unspecified
P00393982Medicare PIN
P42628Medicare UPIN
P3880003Medicare PIN