Provider Demographics
NPI:1629502281
Name:GILLIS, RYAN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:PATRICK
Last Name:GILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CTR
Mailing Address - Street 2:34800 BOB WILSON DRIVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:619-532-6474
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDREN'S WAY
Practice Address - Street 2:RADY CHILDREN'S HOSPITAL SAN DIEGO
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-966-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFELLOW2080P0210X
CAA157437208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN