Provider Demographics
NPI:1396764148
Name:GALLOWAY, AMANDA J (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MEDICAL PKWY
Mailing Address - Street 2:PLAZA 4, SUITE 301
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7858
Mailing Address - Country:US
Mailing Address - Phone:972-247-5464
Mailing Address - Fax:185-599-9924
Practice Address - Street 1:9 MEDICAL PKWY
Practice Address - Street 2:PLAZA 4, SUITE 301
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7858
Practice Address - Country:US
Practice Address - Phone:972-247-5464
Practice Address - Fax:185-599-9924
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183281801Medicaid
TXQ61418Medicare UPIN
TX8G2605Medicare ID - Type Unspecified