Provider Demographics
NPI:1679973390
Name:GALLUP, TASHA (PA-C)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:GALLUP
Suffix:
Gender:F
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 1:16 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-1126
Mailing Address - Country:US
Mailing Address - Phone:603-536-1565
Mailing Address - Fax:603-238-2166
Practice Address - Street 1:103 BOULDER POINT DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3168
Practice Address - Country:US
Practice Address - Phone:603-536-1565
Practice Address - Fax:603-238-2166
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03532255A2300X
NH1256363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer