Provider Demographics
NPI:1871963942
Name:GILLIAM, FREDERICK DWAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:DWAYNE
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:820 S AKERS ST STE 120
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-8306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 S AKERS ST STE 120
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-8306
Practice Address - Country:US
Practice Address - Phone:559-625-4118
Practice Address - Fax:559-625-6004
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA52887363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant