Provider Demographics
NPI:1023572138
Name:TOMBUCON, GLORIA
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:
Last Name:TOMBUCON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 HANALIMA ST APT D101
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-8928
Mailing Address - Country:US
Mailing Address - Phone:808-651-9117
Mailing Address - Fax:
Practice Address - Street 1:1970 HANALIMA ST APT D101
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-8928
Practice Address - Country:US
Practice Address - Phone:808-651-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000343285Medicaid