Provider Demographics
NPI:1285987909
Name:GILGUT, RICHARD CARL (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:CARL
Last Name:GILGUT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-5131
Mailing Address - Country:US
Mailing Address - Phone:530-662-3961
Mailing Address - Fax:
Practice Address - Street 1:1325 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5131
Practice Address - Country:US
Practice Address - Phone:530-662-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU586ZMedicare PIN