Provider Demographics
NPI:1609553205
Name:GAMBOA, ADRIEL IIRAM (PTA)
Entity Type:Individual
Prefix:
First Name:ADRIEL
Middle Name:IIRAM
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33286
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87594-3286
Mailing Address - Country:US
Mailing Address - Phone:505-424-1239
Mailing Address - Fax:
Practice Address - Street 1:3830 COMMONS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5831
Practice Address - Country:US
Practice Address - Phone:505-424-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant