Provider Demographics
NPI:1104051960
Name:GALLEGOS, STEPHANIE LANE (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LANE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 71690
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1690
Mailing Address - Country:US
Mailing Address - Phone:804-285-2300
Mailing Address - Fax:804-285-8420
Practice Address - Street 1:1501 MAPLE AVE
Practice Address - Street 2:SUITE 200 NW MOB
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2553
Practice Address - Country:US
Practice Address - Phone:804-285-2300
Practice Address - Fax:804-285-8420
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA-082363AM0700X
VA0110004398363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical