Provider Demographics
NPI:1669634713
Name:GILLINGHAM, MAI XIONG (PA-C)
Entity type:Individual
Prefix:MS
First Name:MAI XIONG
Middle Name:
Last Name:GILLINGHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MAI XIONG
Other - Middle Name:
Other - Last Name:THAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 TAYLOR BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2147
Mailing Address - Country:US
Mailing Address - Phone:925-677-5041
Mailing Address - Fax:925-677-5025
Practice Address - Street 1:400 TAYLOR BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2147
Practice Address - Country:US
Practice Address - Phone:925-677-5041
Practice Address - Fax:925-677-5025
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2266363A00000X
CAPA21681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21681OtherPA LICENSE