Healthcare Provider Details

I. General information

NPI: 1043638802
Provider Name (Legal Business Name): PATRICK GILLIGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2014
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER ST NE STE 309
ALBUQUERQUE NM
87102-2562
US

IV. Provider business mailing address

4101 INDIAN SCHOOL RD NE STE 110
ALBUQUERQUE NM
87110-3991
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7380
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-727-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2020-0393
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: