Provider Demographics
NPI:1649912049
Name:GAMBILL, LANE D (CTRS)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:D
Last Name:GAMBILL
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 S CORKEY ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7910
Mailing Address - Country:US
Mailing Address - Phone:907-795-5907
Mailing Address - Fax:
Practice Address - Street 1:1145 S CORKEY ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7910
Practice Address - Country:US
Practice Address - Phone:907-795-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist