Provider Demographics
NPI:1699752451
Name:GILLUM, JOHN BARTON JR (PA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BARTON
Last Name:GILLUM
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CTR
Mailing Address - Street 2:9040 A REID ST
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-1110
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR
Practice Address - Street 2:9040 A REID ST
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18972085R0202X, 363A00000X
TXPA03173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200267860AMedicaid
COP00231064OtherRR MEDICARE RIA
OK200039360AMedicaid
WY119732100Medicaid
CO46883355Medicaid
NM66478529Medicaid
TX305251601Medicaid
COC532728Medicare PIN
TX305251601Medicaid
CO46883355Medicaid
TXTXB162941Medicare PIN
COC532748Medicare PIN