Provider Demographics
NPI:1679193163
Name:GAMBOA, BRYANT (DNP)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11262 CAMPUS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11262 CAMPUS STREET
Practice Address - Street 2:WEST HALL L
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350
Practice Address - Country:US
Practice Address - Phone:909-558-4923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95018800363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program