Provider Demographics
NPI:1144602046
Name:GAMBLE, GERALD A
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:GAMBLE
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 1:3602 ENTRADA DR NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3636
Mailing Address - Country:US
Mailing Address - Phone:206-743-6646
Mailing Address - Fax:
Practice Address - Street 1:2330 MOTTMAN RD SW
Practice Address - Street 2:SUITE 106
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6232
Practice Address - Country:US
Practice Address - Phone:360-350-0015
Practice Address - Fax:360-350-0019
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60455558225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist