Provider Demographics
NPI:1922873199
Name:COLLOM, GILLIAN
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:COLLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8250 LAHONTAN DR
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-5162
Mailing Address - Country:US
Mailing Address - Phone:650-575-7788
Mailing Address - Fax:
Practice Address - Street 1:8250 LAHONTAN DR
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-5162
Practice Address - Country:US
Practice Address - Phone:650-575-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant