Provider Demographics
NPI:1508596883
Name:GAMBOA, ANA IRIS
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:IRIS
Last Name:GAMBOA
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 1:4760 S PECOS RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5828
Mailing Address - Country:US
Mailing Address - Phone:702-970-0051
Mailing Address - Fax:
Practice Address - Street 1:4760 S PECOS RD STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5828
Practice Address - Country:US
Practice Address - Phone:702-970-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG510009679560Medicaid