Provider Demographics
NPI:1407904832
Name:GALLAGHER-GONZALES, MICHAELA C (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHAELA
Middle Name:C
Last Name:GALLAGHER-GONZALES
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 1:1923 KIVA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3314
Mailing Address - Country:US
Mailing Address - Phone:505-983-2980
Mailing Address - Fax:505-983-2980
Practice Address - Street 1:2212 BROTHERS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6903
Practice Address - Country:US
Practice Address - Phone:502-983-9460
Practice Address - Fax:505-983-0568
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 94 PA 34363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM 94 PA 34OtherMEDICAL LICENSE
NMNM 94 PA 34OtherMEDICAL LICENSE