Provider Demographics
NPI:1770089930
Name:LABOUFF, FOTTFAM BAGUIO (PA-C)
Entity type:Individual
Prefix:
First Name:FOTTFAM
Middle Name:BAGUIO
Last Name:LABOUFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7240 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3203
Mailing Address - Country:US
Mailing Address - Phone:209-598-3180
Mailing Address - Fax:
Practice Address - Street 1:555 S 43RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4408
Practice Address - Country:US
Practice Address - Phone:215-685-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059727363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical