MEDICARE: MANUELA GALLEGOS PAC

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	363A00000X	Physician Assistant	PA2007-0025	NM
2	363AM0700X	Medical Physician Assistant	PA20070025	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548457997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANUELA GALLEGOS PAC

Provider Business Mailing Address
First Line	:	PO BOX 26666
Second Line	:	PHS PROVIDER ENROLLMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87125-6666
Country	:	US
Telephone Number	:	505-923-6770
Fax Number	:	505-923-5354

Provider Business Practice Location Address
First Line	:	4100 HIGH RESORT BLVD SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87124-5901
Country	:	US
Telephone Number	:	505-462-8809
Fax Number	:	505-462-8468

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

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	08/31/2021

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Directions to “ MANUELA GALLEGOS PAC” Practice Location

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