Provider Demographics
NPI:1992326573
Name:GALUEGO, MIRAH-AIZZA REYES (PA)
Entity type:Individual
Prefix:MS
First Name:MIRAH-AIZZA
Middle Name:REYES
Last Name:GALUEGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:866-682-4842
Mailing Address - Fax:
Practice Address - Street 1:2240 W MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-9667
Practice Address - Country:US
Practice Address - Phone:866-682-4842
Practice Address - Fax:209-667-1269
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60371363A00000X, 363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program