Provider Demographics
NPI:1124684147
Name:GILLEY, AARON CHARLES MARK (LAT, ATC)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:CHARLES MARK
Last Name:GILLEY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 N POTTENGER AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1266
Mailing Address - Country:US
Mailing Address - Phone:580-512-0119
Mailing Address - Fax:
Practice Address - Street 1:500 W UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2522
Practice Address - Country:US
Practice Address - Phone:580-512-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer