Provider Demographics
NPI:1346220415
Name:GALLIMORE, COLLEEN L (PAC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:L
Last Name:GALLIMORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:L
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:3401 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-357-4339
Practice Address - Fax:580-357-4423
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAPA1505363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200073860AMedicaid
Q63423Medicare UPIN
OK245604402Medicare PIN