Basic Information
Provider Information | |||||||||
NPI: | 1346220415 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GALLIMORE | ||||||||
FirstName: | COLLEEN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | COLLEEN | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 785 | ||||||||
Address2: |   | ||||||||
City: | LAWTON | ||||||||
State: | OK | ||||||||
PostalCode: | 73502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5803579984 | ||||||||
FaxNumber: | 5803573277 | ||||||||
Practice Location | |||||||||
Address1: | 3401 W GORE BLVD | ||||||||
Address2: |   | ||||||||
City: | LAWTON | ||||||||
State: | OK | ||||||||
PostalCode: | 73505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5803574339 | ||||||||
FaxNumber: | 5803574423 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 08/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | APA1505 | OK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 200073860A | 05 | OK |   | MEDICAID |