Provider Demographics
NPI:1356084560
Name:GALLEGOS, ANDREW (CPSW)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:CPSW
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 449
Mailing Address - Street 2:
Mailing Address - City:TESUQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87574-0449
Mailing Address - Country:US
Mailing Address - Phone:505-983-6158
Mailing Address - Fax:
Practice Address - Street 1:1000 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2683
Practice Address - Country:US
Practice Address - Phone:505-983-6158
Practice Address - Fax:505-983-0460
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist