Provider Demographics
NPI:1952308694
Name:GALLAHAN, MARY JANE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:GALLAHAN
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:4901 LANG AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4495
Mailing Address - Country:US
Mailing Address - Phone:505-883-2574
Mailing Address - Fax:505-265-4033
Practice Address - Street 1:622 W MAPLE
Practice Address - Street 2:SUITE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-327-4867
Practice Address - Fax:505-327-5355
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP00446751OtherRAILROAD MCRE PTAN
NM89374878Medicaid
NM56576Medicaid
NM56576Medicaid
NM89374878Medicaid
343324604Medicare PIN