Healthcare Provider Details

I. General information

NPI: 1346989795
Provider Name (Legal Business Name): JOHN MASON GALLOWAY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

407 HIGHWAY 874
WINNSBORO LA
71295-6726
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4000
  • Fax:
Mailing address:
  • Phone: 318-535-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number225742
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: