Provider Demographics
NPI:1154805257
Name:GEBALA, MARC JEZER CHAN
Entity type:Individual
Prefix:
First Name:MARC JEZER
Middle Name:CHAN
Last Name:GEBALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W FOOTHILL BLVD UNIT 102
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2452
Mailing Address - Country:US
Mailing Address - Phone:626-841-1660
Mailing Address - Fax:
Practice Address - Street 1:1241 E DYER RD STE 145
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5694
Practice Address - Country:US
Practice Address - Phone:949-538-2073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF10170122363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty