Provider Demographics
NPI:1720618374
Name:GALLUS, DENISE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:LYNN
Last Name:GALLUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:LYNN
Other - Last Name:CLEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1264 CROWN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6556
Mailing Address - Country:US
Mailing Address - Phone:928-899-0192
Mailing Address - Fax:
Practice Address - Street 1:1000 WILLOW CREEK RD STE E
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-583-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1900207VG0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology