Provider Demographics
NPI:1992915144
Name:GILLEY, MARY KATHERINE (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:GILLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:309 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7407
Mailing Address - Country:US
Mailing Address - Phone:318-966-4171
Mailing Address - Fax:
Practice Address - Street 1:309 JACKSON STREET
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-966-4171
Practice Address - Fax:318-966-4856
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1060119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2146416Medicaid
LA2146416Medicaid