Provider Demographics
NPI:1902845571
Name:GILLEN, THOMAS B (PA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:B
Last Name:GILLEN
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:PO BOX 4396
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4396
Mailing Address - Country:US
Mailing Address - Phone:281-955-7577
Mailing Address - Fax:281-955-5875
Practice Address - Street 1:11800 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3840
Practice Address - Country:US
Practice Address - Phone:281-955-7577
Practice Address - Fax:281-955-5875
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N4361OtherBCBS PROVIDER NUMBER
TXQ28090Medicare UPIN
TX8N4361OtherBCBS PROVIDER NUMBER