Provider Demographics
NPI:1184121436
Name:GALLOWAY, MALLORY (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:TOLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:701 E COUNTY LINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1070
Mailing Address - Country:US
Mailing Address - Phone:317-885-2860
Mailing Address - Fax:317-885-2869
Practice Address - Street 1:701 E COUNTY LINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-885-2860
Practice Address - Fax:317-885-2869
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002464A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016778Medicaid