Provider Demographics
NPI:1467538223
Name:LALLY, GABRIELE M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GABRIELE
Middle Name:M
Last Name:LALLY
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 1:315 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:3 PHILIP PAVILION
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4234
Mailing Address - Country:US
Mailing Address - Phone:253-403-2633
Mailing Address - Fax:
Practice Address - Street 1:1708 YAKIMA AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-426-4420
Practice Address - Fax:253-426-4383
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004845363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8431595Medicaid
WA0259143OtherSTATE L&I
335060OtherINTERNAL ID-MOTOR VEHICLE ID
WA20110221364696OtherSTATE L&I
WAG8889471Medicare PIN
WA0259143OtherSTATE L&I
8854175Medicare ID - Type Unspecified