Provider Demographics
NPI:1013994110
Name:GILLUM, PATRICIA L (CRNA)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:L
Last Name:GILLUM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4245 OAK PARK CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-9552
Mailing Address - Country:US
Mailing Address - Phone:817-923-3366
Mailing Address - Fax:972-386-4292
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-882-3680
Practice Address - Fax:817-878-5135
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221908367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0546Medicare ID - Type Unspecified607K
R69864Medicare UPIN