Provider Demographics
NPI:1891723870
Name:GUMBERT, AMANDA WILLIAMS (PA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:WILLIAMS
Last Name:GUMBERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:KRISTINE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6645 ALVARADO RD
Mailing Address - Street 2:SUITE# 4000
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5208
Mailing Address - Country:US
Mailing Address - Phone:619-810-1010
Mailing Address - Fax:619-810-1011
Practice Address - Street 1:6645 ALVARADO RD
Practice Address - Street 2:SUITE# 4000
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:619-810-1010
Practice Address - Fax:619-810-1011
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18153363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18153Medicaid
CAPA18153Medicaid