Provider Demographics
NPI:1861087348
Name:GALLUP, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GALLUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 MEADOW WOOD LN
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-2207
Mailing Address - Country:US
Mailing Address - Phone:804-307-7193
Mailing Address - Fax:
Practice Address - Street 1:3408 MEADOW WOOD LN
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-2207
Practice Address - Country:US
Practice Address - Phone:804-307-7193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2278C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2278C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedCritical CareGroup - Single Specialty