Provider Demographics
NPI:1275870628
Name:OMBAO, JOEL GALLANO (NP-C)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:GALLANO
Last Name:OMBAO
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 HULEN PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2606
Mailing Address - Country:US
Mailing Address - Phone:951-595-4444
Mailing Address - Fax:951-462-1034
Practice Address - Street 1:2880 HULEN PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2606
Practice Address - Country:US
Practice Address - Phone:951-595-4444
Practice Address - Fax:951-462-1034
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22676363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily