Healthcare Provider Details

I. General information

NPI: 1114574084
Provider Name (Legal Business Name): SAMANTHA JO GALLO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2019
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 E HERNDON AVE
FRESNO CA
93720-3235
US

IV. Provider business mailing address

1245 E HERNDON AVE
FRESNO CA
93720-3235
US

V. Phone/Fax

Practice location:
  • Phone: 559-664-4000
  • Fax: 559-675-5224
Mailing address:
  • Phone: 559-664-4000
  • Fax: 559-675-5224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: