Healthcare Provider Details

I. General information

NPI: 1699752451
Provider Name (Legal Business Name): JOHN BARTON GILLUM JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CTR 9040 A REID ST
TACOMA WA
98431-0001
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CTR 9040 A REID ST
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone: 253-968-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1897
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03173
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1897
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: