Provider Demographics
NPI:1265209977
Name:GIMBALLA, FUSEINA
Entity type:Individual
Prefix:
First Name:FUSEINA
Middle Name:
Last Name:GIMBALLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 KATHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-1158
Mailing Address - Country:US
Mailing Address - Phone:462-867-6456
Mailing Address - Fax:
Practice Address - Street 1:462 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-9196
Practice Address - Country:US
Practice Address - Phone:212-263-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical