Provider Demographics
NPI:1750445300
Name:GALLANT, MARY ALICE (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:GALLANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2061 EXPERIMENT STATION RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-5328
Mailing Address - Country:US
Mailing Address - Phone:706-310-0324
Mailing Address - Fax:
Practice Address - Street 1:2061 EXPERIMENT STATION RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:706-310-0324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant