Provider Demographics
NPI:1588916407
Name:GALLAS, KIRSTIN E (PA)
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:E
Last Name:GALLAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIRSTIN
Other - Middle Name:E
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-5904
Mailing Address - Fax:312-563-6064
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 1010
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5904
Practice Address - Fax:312-563-6064
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant