Provider Demographics
NPI:1386217883
Name:GALLAGHER, CONNER
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36459 RHUBARB CT
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8693
Mailing Address - Country:US
Mailing Address - Phone:714-549-8798
Mailing Address - Fax:
Practice Address - Street 1:6859 MAGNOLIA AVE STE 1
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2866
Practice Address - Country:US
Practice Address - Phone:951-824-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily