Provider Demographics
NPI:1265182810
Name:GILLIAM, TIMOTHY W (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:GILLIAM
Suffix:
Gender:M
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 1:1571 WASHINGTON STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-782-1650
Mailing Address - Fax:315-788-8547
Practice Address - Street 1:1571 WASHINGTON STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-1650
Practice Address - Fax:315-788-8547
Is Sole Proprietor?:No
Enumeration Date:2022-03-26
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY029490363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07558372Medicaid