1104051960 NPI number — MS. STEPHANIE LANE GALLEGOS P.A.-C

Table of content: MS. STEPHANIE LANE GALLEGOS P.A.-C (NPI 1104051960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104051960 NPI number — MS. STEPHANIE LANE GALLEGOS P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLEGOS
Provider First Name:
STEPHANIE
Provider Middle Name:
LANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104051960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 71690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23255-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-285-2300
Provider Business Mailing Address Fax Number:
804-285-8420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 MAPLE AVE
Provider Second Line Business Practice Location Address:
SUITE 200 NW MOB
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23226-2553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-285-2300
Provider Business Practice Location Address Fax Number:
804-285-8420
Provider Enumeration Date:
05/22/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA-082 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 0110004398 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)