Provider Demographics
NPI:1639758980
Name:GILLIS, NEVIN (MD)
Entity Type:Individual
Prefix:
First Name:NEVIN
Middle Name:
Last Name:GILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TURTLE LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58575-4001
Mailing Address - Country:US
Mailing Address - Phone:877-609-3577
Mailing Address - Fax:
Practice Address - Street 1:128 FOUSSARD AVE NW
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:ND
Practice Address - Zip Code:58369
Practice Address - Country:US
Practice Address - Phone:701-477-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19747208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice