Basic Information
| Provider Information | |||||||||
| NPI: | 1508116989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLEGOS | ||||||||
| FirstName: | STEVEN | ||||||||
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| Credential: | ACNP/FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195895161 | ||||||||
| FaxNumber: | 7195895722 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 VINE AVE | ||||||||
| Address2: | |||||||||
| City: | LAS ANIMAS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194562653 | ||||||||
| FaxNumber: | 7194560105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 09/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | NP-10184 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | NP-10184 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 58304568 | 05 | CO | MEDICAID |