Provider Demographics
NPI:1104188192
Name:GAMBOA, JESSICA-RENEE (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA-RENEE
Middle Name:
Last Name:GAMBOA
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 1:301 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73523-5004
Mailing Address - Country:US
Mailing Address - Phone:580-481-5062
Mailing Address - Fax:
Practice Address - Street 1:301 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73523-5004
Practice Address - Country:US
Practice Address - Phone:580-481-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR3326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty