Basic Information
| Provider Information | |||||||||
| NPI: | 1063470557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLAGHER | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | ATT: CVMC FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023714365 | ||||||||
| FaxNumber: | 8023714481 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056029516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023714365 | ||||||||
| FaxNumber: | 8023714481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 586 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 055.0031114 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000545 | 05 | VT | MEDICAID |