Provider Demographics
NPI:1063470557
Name:GALLAGHER, JACQUELINE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-371-4365
Mailing Address - Fax:802-371-4481
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4365
Practice Address - Fax:802-371-4481
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA586363A00000X
VT055.0031114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000545Medicaid
P01331Medicare UPIN
VT9000545Medicaid
VTAP033804Medicare PIN