Provider Demographics
NPI:1932479136
Name:GILLMAN, MARGO L (PA-C)
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:L
Last Name:GILLMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 E GRAND RIVER AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-4335
Mailing Address - Country:US
Mailing Address - Phone:517-364-8627
Mailing Address - Fax:
Practice Address - Street 1:2909 E GRAND RIVER AVE STE 102
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4335
Practice Address - Country:US
Practice Address - Phone:517-364-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004113363A00000X
MI5601007010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant