Healthcare Provider Details

I. General information

NPI: 1871963942
Provider Name (Legal Business Name): FREDERICK DWAYNE GILLIAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S AKERS ST STE 120
VISALIA CA
93277-8306
US

IV. Provider business mailing address

820 S AKERS ST STE 120
VISALIA CA
93277-8306
US

V. Phone/Fax

Practice location:
  • Phone: 559-625-4118
  • Fax: 559-625-6004
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number52887
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number52887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: