Provider Demographics
NPI:1891775599
Name:GILLES, DANIEL J (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:GILLES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 PINE ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-1297
Mailing Address - Country:US
Mailing Address - Phone:715-644-5530
Mailing Address - Fax:715-644-6623
Practice Address - Street 1:1120 PINE ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-1297
Practice Address - Country:US
Practice Address - Phone:715-644-5530
Practice Address - Fax:715-644-6223
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42978600Medicaid
WI11068-0011OtherWPS PART B
WI42978600Medicaid