Healthcare Provider Details

I. General information

NPI: 1417620618
Provider Name (Legal Business Name): ERIC GILLIES NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 WILKINS CIR
CASPER WY
82601-1337
US

IV. Provider business mailing address

1441 WILKINS CIR
CASPER WY
82601-1337
US

V. Phone/Fax

Practice location:
  • Phone: 307-233-2700
  • Fax: 307-472-2883
Mailing address:
  • Phone: 307-233-2700
  • Fax: 307-472-2883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number40289
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number50974
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: