Provider Demographics
NPI:1467425579
Name:GALLUP, PEGGY GRANDY (NP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:GRANDY
Last Name:GALLUP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 NORTH 3RD STREET
Mailing Address - Street 2:SUITE 4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4608
Mailing Address - Country:US
Mailing Address - Phone:602-323-3345
Mailing Address - Fax:602-323-3499
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN084459363L00000X
AZA6793363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000037Medicaid
AZZ145342Medicare PIN
108051Medicare PIN
Q63228Medicare UPIN
AZ000037Medicaid
AZZ155055Medicare PIN