Provider Demographics
NPI:1568405983
Name:GAMBLE, LISA KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KATHLEEN
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WILSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3130 DEL MONTE BLVD
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-3047
Practice Address - Country:US
Practice Address - Phone:831-883-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA139251Medicare ID - Type Unspecified
CAS72914Medicare UPIN