Provider Demographics
NPI:1720663503
Name:GALLEGOS MEDINA, LUIS GILMER (SA-C)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GILMER
Last Name:GALLEGOS MEDINA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44360 SUNSET MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3890
Mailing Address - Country:US
Mailing Address - Phone:571-762-9435
Mailing Address - Fax:
Practice Address - Street 1:44360 SUNSET MAPLE DR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3890
Practice Address - Country:US
Practice Address - Phone:571-762-9435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA21-170246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant