Provider Demographics
NPI:1043716913
Name:GAMBOA, NICHOLAS T (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:T
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N MEDICAL DRIVE EAST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132
Mailing Address - Country:US
Mailing Address - Phone:801-581-6908
Mailing Address - Fax:801-581-4385
Practice Address - Street 1:175 N MEDICAL DRIVE EAST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-6908
Practice Address - Fax:801-581-4385
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program