MEDICARE: MARK EDWARD GALLEGOS PA

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	PA756	NV
2	363A00000X	Physician Assistant	PA18490	CA

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649240722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EDWARD GALLEGOS PA

Provider Business Mailing Address
First Line	:	FILE # 54433
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-0001
Country	:	US
Telephone Number	:	858-784-5767
Fax Number	:	858-784-5644

Provider Business Practice Location Address
First Line	:	15025 INNOVATION DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-3409
Country	:	US
Telephone Number	:	858-487-1800
Fax Number	:	858-784-5644

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	06/19/2014

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Directions to “ MARK EDWARD GALLEGOS PA” Practice Location

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