Provider Demographics
NPI:1861669541
Name:MILLS, GREGORY D (PAC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:MILLS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:623 N. 9TH STREET
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-3314
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:300 EAST MAIN
Practice Address - Street 2:
Practice Address - City:SWIFTON
Practice Address - State:AR
Practice Address - Zip Code:72471-0000
Practice Address - Country:US
Practice Address - Phone:870-347-2534
Practice Address - Fax:870-347-3492
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA 258363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57297Medicare PIN
AR57297P189Medicare PIN