Provider Demographics
NPI:1770194656
Name:GAMBOA, MARIA JOSE (PTA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JOSE
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 CLEARY BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1349
Mailing Address - Country:US
Mailing Address - Phone:954-309-7602
Mailing Address - Fax:
Practice Address - Street 1:8020 CLEARY BLVD APT 207
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1349
Practice Address - Country:US
Practice Address - Phone:954-309-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30483208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation