MEDICARE: HOLLY MARIE GALLEGOS P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA02027	TX

General Provider Information

NPI Number	:	1164466595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY MARIE GALLEGOS P.A.

Provider Business Mailing Address
First Line	:	12221 MERIT DR
Second Line	:	STE 1610
City	:	DALLAS
State	:	TX
Zip	:	75251-2202
Country	:	US
Telephone Number	:	214-217-1911
Fax Number	:	214-217-1912

Provider Business Practice Location Address
First Line	:	12221 MERIT DR
Second Line	:	STE 1610
City	:	DALLAS
State	:	TX
Zip	:	75251-2202
Country	:	US
Telephone Number	:	214-217-1911
Fax Number	:	214-217-1912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	03/14/2008

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