Healthcare Provider Details

I. General information

NPI: 1316968100
Provider Name (Legal Business Name): GORDON DEREK CALLAWAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5599
  • Fax:
Mailing address:
  • Phone: 603-650-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0592
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: