Provider Demographics
NPI:1629246574
Name:GILLCOAT, CHARLSIE FERGUSON (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLSIE
Middle Name:FERGUSON
Last Name:GILLCOAT
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:CHARLSIE
Other - Middle Name:ELIZABETH
Other - Last Name:FERGUSON / PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:505 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6604
Mailing Address - Country:US
Mailing Address - Phone:903-501-5056
Mailing Address - Fax:903-499-5056
Practice Address - Street 1:505 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6604
Practice Address - Country:US
Practice Address - Phone:903-501-5056
Practice Address - Fax:903-499-5056
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP116578363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193683302Medicaid
TX193683302Medicaid