Provider Demographics
NPI:1831298918
Name:GILLAND, MARK T (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:GILLAND
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 N LIMESTONE # 2135
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-3247
Mailing Address - Country:US
Mailing Address - Phone:888-790-0743
Mailing Address - Fax:859-252-9738
Practice Address - Street 1:1532 N LIMESTONE # 2135
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-3247
Practice Address - Country:US
Practice Address - Phone:888-790-0743
Practice Address - Fax:859-252-9738
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002698367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74269804Medicaid
KYK133911Medicare PIN