Basic Information
| Provider Information | |||||||||
| NPI: | 1669634713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLINGHAM | ||||||||
| FirstName: | MAI XIONG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THAO | ||||||||
| OtherFirstName: | MAI XIONG | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 TAYLOR BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945232147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256775041 | ||||||||
| FaxNumber: | 9256775025 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 TAYLOR BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945232147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256775041 | ||||||||
| FaxNumber: | 9256775025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2266 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA21681 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.