Healthcare Provider Details

I. General information

NPI: 1700301637
Provider Name (Legal Business Name): DALLIN SHAW GALLACHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5444 S GREEN ST
MURRAY UT
84123-5632
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-313-4118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11146590-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: