Provider Demographics
NPI:1528467248
Name:GALLOWAY, AMANDA M (PAC)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:M
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:BOILEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1038-1050 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:
Practice Address - Street 1:1038-1050 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003131363A00000X
MAPA5130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMB0971780JOtherSTATE CONTROLLED SUBSTANCE REGISTRATION
MA110028120Medicaid
MAMB3308740OtherFEDERAL DEA (CONTROLLED SUBSTANCE REGISTRATION)
MA110028120Medicaid
MAS400176998Medicare UPIN
MAMB3308740OtherFEDERAL DEA (CONTROLLED SUBSTANCE REGISTRATION)