Provider Demographics
NPI:1265415871
Name:GALLAGHER, JUDITH ANN (CRNA)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-2585
Mailing Address - Country:US
Mailing Address - Phone:706-660-8505
Mailing Address - Fax:706-660-9390
Practice Address - Street 1:100 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2130
Practice Address - Country:US
Practice Address - Phone:814-676-7843
Practice Address - Fax:814-676-7838
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN132769L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015509530025OtherMEDICAID GROUP
PA808862OtherMEDICARE GROUP
PA1015496050001Medicaid
PA808862OtherMEDICARE GROUP