Provider Demographics
NPI:1992955363
Name:GALLEGOS, DANIEL (ANP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10645 N TATUM BLVD
Mailing Address - Street 2:STE 200-152
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3068
Mailing Address - Country:US
Mailing Address - Phone:602-380-6012
Mailing Address - Fax:480-287-9269
Practice Address - Street 1:10645 N TATUM BLVD
Practice Address - Street 2:200-152
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3068
Practice Address - Country:US
Practice Address - Phone:602-380-6012
Practice Address - Fax:480-287-9269
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3383363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ472262Medicaid
AZZ133106Medicare PIN
AZZ133106Medicare PIN