Healthcare Provider Details

I. General information

NPI: 1548457997
Provider Name (Legal Business Name): MANUELA GALLEGOS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 HIGH RESORT BLVD SE
ALBUQUERQUE NM
87124-5901
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-8809
  • Fax: 505-462-8468
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2007-0025
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA20070025
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: