Provider Demographics
NPI:1336736750
Name:GAMBOA, YONATHAN
Entity Type:Individual
Prefix:MR
First Name:YONATHAN
Middle Name:
Last Name:GAMBOA
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 1:966 W MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3017
Mailing Address - Country:US
Mailing Address - Phone:209-643-9420
Mailing Address - Fax:
Practice Address - Street 1:966 W MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3017
Practice Address - Country:US
Practice Address - Phone:209-643-9420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental