Provider Demographics
NPI:1932594504
Name:GILLIS, KYLE ANDREW (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:GILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 NE MULTNOMAH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9900 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9777
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD205989208800000X
IAMD-47153208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology