Provider Demographics
NPI:1891304887
Name:FON, GIDEON TAH
Entity Type:Individual
Prefix:
First Name:GIDEON
Middle Name:TAH
Last Name:FON
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 1:6 ROCK STORY CT
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2844
Mailing Address - Country:US
Mailing Address - Phone:443-676-6123
Mailing Address - Fax:
Practice Address - Street 1:6 ROCK STORY CT
Practice Address - Street 2:NONE
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2844
Practice Address - Country:US
Practice Address - Phone:443-676-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134373363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health