Provider Demographics
NPI:1649240722
Name:GALLEGOS, MARK EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE # 54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:858-784-5767
Mailing Address - Fax:858-784-5644
Practice Address - Street 1:15025 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3409
Practice Address - Country:US
Practice Address - Phone:858-487-1800
Practice Address - Fax:858-784-5644
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA756363A00000X
CAPA18490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2402526Medicaid
NV3102526Medicaid
NVV107203Medicare PIN
CAWPA18490AMedicare PIN
NV37161Medicare ID - Type Unspecified
NV3102526Medicaid