Provider Demographics
NPI:1346846581
Name:GALLIVAN, KATHERINE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:GALLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BECKS WOODS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-3853
Mailing Address - Country:US
Mailing Address - Phone:866-862-2955
Mailing Address - Fax:302-836-4302
Practice Address - Street 1:121 BECKS WOODS DR STE 100
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-3853
Practice Address - Country:US
Practice Address - Phone:866-862-2955
Practice Address - Fax:302-836-4302
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011476.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical