Provider Demographics
NPI:1649639931
Name:GALLEGOS, IAN RICARDO (PTA)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:RICARDO
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 MISSION ARCH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8307
Mailing Address - Country:US
Mailing Address - Phone:575-624-2583
Mailing Address - Fax:575-623-8949
Practice Address - Street 1:3200 MISSION ARCH DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-8307
Practice Address - Country:US
Practice Address - Phone:575-624-2583
Practice Address - Fax:575-623-8949
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1601225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant