Provider Demographics
NPI:1902295603
Name:GUILLO, CHRISTOPHER ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:GUILLO
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 1:206 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-2298
Mailing Address - Fax:662-534-2330
Practice Address - Street 1:6011 AIRLINE RD STE 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-9916
Practice Address - Country:US
Practice Address - Phone:901-557-7077
Practice Address - Fax:901-592-4482
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
TN3332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1902295603Medicare PIN