Provider Demographics
NPI:1154704708
Name:GILLIAM, GARY (FNP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17285 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:DUNGANNON
Mailing Address - State:VA
Mailing Address - Zip Code:24245-3937
Mailing Address - Country:US
Mailing Address - Phone:276-467-2201
Mailing Address - Fax:276-467-2673
Practice Address - Street 1:17285 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:DUNGANNON
Practice Address - State:VA
Practice Address - Zip Code:24245-3937
Practice Address - Country:US
Practice Address - Phone:276-467-2201
Practice Address - Fax:276-467-2673
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172696363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily