Provider Demographics
NPI:1508116989
Name:GALLEGOS, STEVEN (ACNP/FNP-BC)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:ACNP/FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-589-5161
Mailing Address - Fax:719-589-5722
Practice Address - Street 1:245 VINE AVE
Practice Address - Street 2:
Practice Address - City:LAS ANIMAS
Practice Address - State:CO
Practice Address - Zip Code:81054
Practice Address - Country:US
Practice Address - Phone:719-456-2653
Practice Address - Fax:719-456-0105
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP-10184363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58304568Medicaid