Provider Demographics
NPI:1659535789
Name:GILLIAM, JOSH (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:14547 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2709
Practice Address - Country:US
Practice Address - Phone:813-979-0440
Practice Address - Fax:813-355-5054
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000340900Medicaid
FLP00982255OtherRR MEDICARE
FLP00982255OtherRR MEDICARE
FL000340900Medicaid