Provider Demographics
NPI:1295789428
Name:ROSICKY, GILLIAN C
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:C
Last Name:ROSICKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GILLIAN
Other - Middle Name:C
Other - Last Name:GUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4015 MERCANTILE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2552
Practice Address - Country:US
Practice Address - Phone:503-216-1500
Practice Address - Fax:503-216-1515
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR096007017RN163W00000X
OR200050079NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00396908OtherRR MEDICARE - PHS
OR262381Medicaid
ORP00396908OtherRR MEDICARE - PHS
ORP25398Medicare UPIN