Individual
MR. IRA RICHARD GILLUM
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
PA C
Contact information
Practice address
104 S DEVINE, GROVETON, TX 75845-0104
(936) 642-0841
(936) 642-0849
Mailing address
PO BOX 459, 104 S DEVINE, GROVETON, TX 75845-0459
(936) 642-0841
(936) 642-0849
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA 00013
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PA 00013
LICENSE
TX
Enumeration date
11/21/2005
Last updated
07/08/2007
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