Healthcare Provider Details

I. General information

NPI: 1053836809
Provider Name (Legal Business Name): ALYSHA GALLEGOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2017
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 HIGH RESORT BLVD SE
RIO RANCHO 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: 505-462-8520
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2017-0061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: