Provider Demographics
NPI:1922026467
Name:GILLESPIE, ROBERT TODD (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TODD
Last Name:GILLESPIE
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 126
Mailing Address - Street 2:SUITE B
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-0126
Mailing Address - Country:US
Mailing Address - Phone:208-766-2231
Mailing Address - Fax:208-766-4819
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:SUITE B
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1256
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805203600Medicaid
ID970011284OtherRAILROAD MEDICARE PTAN
ID805203600Medicaid