Provider Demographics
NPI:1821755513
Name:FOTABONG, GALLUS LEREH
Entity Type:Individual
Prefix:MR
First Name:GALLUS
Middle Name:LEREH
Last Name:FOTABONG
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 1:41 HARVEST ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-1122
Mailing Address - Country:US
Mailing Address - Phone:781-244-8473
Mailing Address - Fax:
Practice Address - Street 1:41 HARVEST ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-1122
Practice Address - Country:US
Practice Address - Phone:781-244-8473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAG11210066363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology