Healthcare Provider Details

I. General information

NPI: 1255499125
Provider Name (Legal Business Name): MARCELLO LABRADOR GAYAHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SMITH AVE N 500
ST PAUL MN
55102
US

IV. Provider business mailing address

225 SMITH AVE N 500
ST PAUL MN
55102
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-0616
  • Fax: 651-379-4484
Mailing address:
  • Phone: 651-292-0616
  • Fax: 651-379-4484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: