Provider Demographics
NPI:1265117659
Name:WAMBEBE, BALA MICHAEL
Entity type:Individual
Prefix:
First Name:BALA MICHAEL
Middle Name:
Last Name:WAMBEBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 SOUTH GREENFIELD ROAD
Mailing Address - Street 2:APT. #2085
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295
Mailing Address - Country:US
Mailing Address - Phone:915-228-0283
Mailing Address - Fax:
Practice Address - Street 1:2910 SOUTH GREENFIELD ROAD
Practice Address - Street 2:APT. #2085
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:915-228-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ226621363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health