Provider Demographics
NPI:1841268737
Name:GILLIAM, EARNEST EDWARD JR (APN)
Entity type:Individual
Prefix:MR
First Name:EARNEST
Middle Name:EDWARD
Last Name:GILLIAM
Suffix:JR
Gender:M
Credentials:APN
Other - Prefix:MR
Other - First Name:EDDIE
Other - Middle Name:
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN-CRNA
Mailing Address - Street 1:PO BOX 771522
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-1522
Mailing Address - Country:US
Mailing Address - Phone:901-747-4624
Mailing Address - Fax:901-261-2542
Practice Address - Street 1:1801 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-8998
Practice Address - Country:US
Practice Address - Phone:870-816-3780
Practice Address - Fax:901-261-2542
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000009307367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11376597OtherCAQH
AR1841268737OtherBAPTIST HEALTH SERVICES GROUP, INC.
AR1841268737OtherARKANSAS BLUE CROSS BLUE SHIELD
AR1841268737OtherCIGNA
AR1841268737OtherUNITED HEALTHCARE
AR1841268737OtherUNITED HEALTHCARE
AR403426YNETMedicare PIN