Healthcare Provider Details

I. General information

NPI: 1679973390
Provider Name (Legal Business Name): TASHA GALLUP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BOULDER POINT DR STE 1
PLYMOUTH NH
03264-3170
US

IV. Provider business mailing address

101 BOULDER POINT DR STE 1
PLYMOUTH NH
03264-3170
US

V. Phone/Fax

Practice location:
  • Phone: 603-536-4000
  • Fax: 603-536-4001
Mailing address:
  • Phone: 603-536-4000
  • Fax: 603-536-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1256
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0353
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: