Basic Information
| Provider Information | |||||||||
| NPI: | 1699752451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLUM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BARTON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
| Address2: | 9040 A REID ST | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539681110 | ||||||||
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| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
| Address2: | 9040 A REID ST | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539681110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 1897 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 363A00000X | 1897 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA03173 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200267860A | 05 | KS | MEDICAID | P00231064 | 01 | CO | RR MEDICARE RIA | OTHER | 200039360A | 05 | OK | MEDICAID | 119732100 | 05 | WY | MEDICAID | 46883355 | 05 | CO | MEDICAID | 66478529 | 05 | NM | MEDICAID | 305251601 | 05 | TX | MEDICAID |