Provider Demographics
NPI:1518965375
Name:GALLOWAY, MARK JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:GALLOWAY
Suffix:
Gender:M
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 1:2185 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-6418
Mailing Address - Country:US
Mailing Address - Phone:843-527-1800
Mailing Address - Fax:843-527-6528
Practice Address - Street 1:2185 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6418
Practice Address - Country:US
Practice Address - Phone:843-527-1800
Practice Address - Fax:843-527-6528
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA100036000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA137313OtherLABOR AND INDUSTRIES
WA7089519Medicaid
SCAA9868A420Medicare UPIN
WAS25984Medicare UPIN
WAAB1478Medicare ID - Type Unspecified
SCA420Medicare PIN