Basic Information
| Provider Information | |||||||||
| NPI: | 1952374381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLILAND | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | THAINE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1241 W MINERAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037590854 | ||||||||
| FaxNumber: | 3037590864 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 PRAIRIE CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806014006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034581600 | ||||||||
| FaxNumber: | 3036548170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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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 | 363A00000X | 104 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 07010408 | 05 | CO | MEDICAID | 970016341 | 01 | CO | RR MEDICARE | OTHER |