Provider Demographics
NPI:1194748202
Name:GALLEGOS, MYRNA M (NP-C)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:M
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:M
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-839-2300
Mailing Address - Fax:505-839-2303
Practice Address - Street 1:2929 COORS BLVD NW
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1173
Practice Address - Country:US
Practice Address - Phone:505-839-2328
Practice Address - Fax:505-839-2303
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00260363LF0000X
NMR18208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH4698Medicaid
NMH4698Medicaid