Healthcare Provider Details

I. General information

NPI: 1790294585
Provider Name (Legal Business Name): MARC-ANDRE GASCON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-3309
US

IV. Provider business mailing address

3400 SPRUCE ST
PHILADELPHIA PA
19104-3309
US

V. Phone/Fax

Practice location:
  • Phone: 215-349-8310
  • Fax: 215-893-7270
Mailing address:
  • Phone: 215-349-8310
  • Fax: 215-893-7270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA063516
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: