Provider Demographics
NPI:1902904170
Name:GALLAGHER, ROGER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-1994
Mailing Address - Country:US
Mailing Address - Phone:850-277-0070
Mailing Address - Fax:
Practice Address - Street 1:615 N BONITA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3623
Practice Address - Country:US
Practice Address - Phone:850-747-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 868172367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG1283VMedicare UPIN