Provider Demographics
NPI:1750474821
Name:GILLMAN, JONATHAN JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAMES
Last Name:GILLMAN
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 1:6232 KARLSRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-8402
Mailing Address - Country:US
Mailing Address - Phone:937-436-5763
Mailing Address - Fax:937-436-7399
Practice Address - Street 1:5491 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2325
Practice Address - Country:US
Practice Address - Phone:937-436-5763
Practice Address - Fax:937-436-7399
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ62064Medicare UPIN
OHGIPA26351Medicare ID - Type Unspecified