Healthcare Provider Details

I. General information

NPI: 1235146960
Provider Name (Legal Business Name): KATHERINE ANNE GILLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 WAKE FOREST RD SUITE 512
RALEIGH NC
27609-7300
US

IV. Provider business mailing address

508 LOBLOLLY DR
DURHAM NC
27712-8723
US

V. Phone/Fax

Practice location:
  • Phone: 919-862-5970
  • Fax: 919-862-5975
Mailing address:
  • Phone: 919-765-5957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number104096
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: