Provider Demographics
NPI:1184821464
Name:GALVIN, COLLEEN MARIE (PA, LAC, NMD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:GALVIN
Suffix:
Gender:F
Credentials:PA, LAC, NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 E 17TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3855
Mailing Address - Country:US
Mailing Address - Phone:949-715-9686
Mailing Address - Fax:
Practice Address - Street 1:347 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6348
Practice Address - Country:US
Practice Address - Phone:562-430-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant