Provider Demographics
NPI:1629469093
Name:GALLANT, BRIAN S (NP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:GALLANT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7720
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-0720
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-3183
Practice Address - Street 1:428 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3000
Practice Address - Fax:203-503-3224
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT7437363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7437OtherAPRN
CT008077937Medicaid
CTCSP.0067398OtherCSR
CTCSP.0067398OtherCSR