Provider Demographics
NPI:1699836593
Name:GILLAN, LEROY E (CRNA)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:E
Last Name:GILLAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 CENTRAL DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6000
Mailing Address - Country:US
Mailing Address - Phone:817-268-0104
Mailing Address - Fax:817-268-6102
Practice Address - Street 1:1600 CENTRAL DR
Practice Address - Street 2:SUITE 160
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6000
Practice Address - Country:US
Practice Address - Phone:817-268-0104
Practice Address - Fax:817-268-6102
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010720367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037214601Medicaid
KY180403400OtherDEPT OF LABOR KENTUCKY
TX430042809OtherRAILROAD MEDICARE
TXCRNA10720OtherTEXAS WC
TX81179UOtherBLUE SHIELD OF TEXAS
OH006895499OtherEEOICP WC
TX81179UOtherBLUE SHIELD OF TEXAS
KY180403400OtherDEPT OF LABOR KENTUCKY