Provider Demographics
NPI:1336396548
Name:GILLIAM-UDO, BRENITTA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRENITTA
Middle Name:
Last Name:GILLIAM-UDO
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 1:25064 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2830
Mailing Address - Country:US
Mailing Address - Phone:909-569-3576
Mailing Address - Fax:
Practice Address - Street 1:351 N MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-1018
Practice Address - Country:US
Practice Address - Phone:714-748-8955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant