Provider Demographics
NPI:1144305467
Name:GALASSO, GWENDOLYN (MD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:GALASSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 ROUTE 315
Mailing Address - Street 2:
Mailing Address - City:WILKES-BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-7012
Mailing Address - Country:US
Mailing Address - Phone:570-825-8741
Mailing Address - Fax:570-825-8990
Practice Address - Street 1:2888 SR 29 S STE 1
Practice Address - Street 2:MONROE-NOXEN HEALTH CENTER
Practice Address - City:MONROE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18636-7854
Practice Address - Country:US
Practice Address - Phone:570-298-2121
Practice Address - Fax:570-298-2148
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042720E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E64294Medicare UPIN