Provider Demographics
NPI:1750633442
Name:GAMBOA, GERALDINE (PT)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939-1 GOETHALS ROAD NORTH
Mailing Address - Street 2:UNIT 1
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303
Mailing Address - Country:US
Mailing Address - Phone:347-675-8223
Mailing Address - Fax:
Practice Address - Street 1:939 GOETHALS ROAD NORTH
Practice Address - Street 2:UNIT 1
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303
Practice Address - Country:US
Practice Address - Phone:347-675-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019272-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist