Provider Demographics
NPI:1609833078
Name:GILLEN, MARK R (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:GILLEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:6160 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1930
Practice Address - Country:US
Practice Address - Phone:918-495-2600
Practice Address - Fax:918-497-3007
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2013-08-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100062820AMedicaid
OKP54238Medicare UPIN
OK24H620525Medicare PIN
OK24H619019Medicare PIN
OK243419100Medicare PIN
OKP00194297Medicare PIN
OK970025211Medicare PIN