Healthcare Provider Details

I. General information

NPI: 1841710969
Provider Name (Legal Business Name): REBECCA OPAL GILLILAN PA -C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BECCA GILLILAN

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 TROUSDALE DR
BURLINGAME CA
94010-4506
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-8787
  • Fax:
Mailing address:
  • Phone: 650-652-8787
  • Fax: 847-618-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: