Provider Demographics
NPI:1679552749
Name:GALLEGOS, MARIA GWEN (FNP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:GWEN
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2819
Mailing Address - Country:US
Mailing Address - Phone:520-792-9890
Mailing Address - Fax:
Practice Address - Street 1:1209 W TARGET RANGE RD
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2466
Practice Address - Country:US
Practice Address - Phone:520-287-4747
Practice Address - Fax:520-285-3135
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN037699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ516362Medicaid
62076Medicare ID - Type Unspecified
AZ516362Medicaid