Provider Demographics
NPI:1841372273
Name:GILLIAM, PHILLIP SCOTT (PA)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:SCOTT
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66201-0838
Mailing Address - Country:US
Mailing Address - Phone:913-469-4244
Mailing Address - Fax:913-469-1939
Practice Address - Street 1:1509 W TRUMAN RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-3436
Practice Address - Country:US
Practice Address - Phone:816-836-6901
Practice Address - Fax:816-836-4400
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2005017775363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant