Provider Demographics
NPI:1952936353
Name:GILLINGHAM, TYLER ZACHARY (NP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ZACHARY
Last Name:GILLINGHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5100
Mailing Address - Country:US
Mailing Address - Phone:617-247-7555
Mailing Address - Fax:617-638-0033
Practice Address - Street 1:142 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5100
Practice Address - Country:US
Practice Address - Phone:617-247-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2328949163WP2201X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care