MEDICARE: KATELYN GILLESPIE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	PA.0009537	CO

General Provider Information

NPI Number	:	1366310591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN GILLESPIE

Provider Business Mailing Address
First Line	:	4201 HENRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-5409
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 HENRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-5409
Country	:	US
Telephone Number	:	215-951-0208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2025
Last Update Date	:	01/12/2026

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