Basic Information
| Provider Information | |||||||||
| NPI: | 1083726459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 E COURT ST | ||||||||
| Address2: | |||||||||
| City: | SEGUIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781555129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303039400 | ||||||||
| FaxNumber: | 8303039420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1761 HIGHWAY 46 W STE 104 | ||||||||
| Address2: | |||||||||
| City: | NEW BRAUNFELS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781324750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306081575 | ||||||||
| FaxNumber: | 8306080868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03687 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | H0143584 | 01 | TX | DPS | OTHER | PA03687 | 01 | TX | LICENSE | OTHER | 218278401 | 05 | TX | MEDICAID | MG1351294 | 01 | TX | DEA | OTHER |