Healthcare Provider Details

I. General information

NPI: 1891723870
Provider Name (Legal Business Name): AMANDA WILLIAMS GUMBERT P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA KRISTINE WILLIAMS P.A

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6645 ALVARADO RD SUITE# 4000
SAN DIEGO CA
92120-5208
US

IV. Provider business mailing address

6645 ALVARADO RD SUITE# 4000
SAN DIEGO CA
92120-5208
US

V. Phone/Fax

Practice location:
  • Phone: 619-810-1010
  • Fax: 619-810-1011
Mailing address:
  • Phone: 619-810-1010
  • Fax: 619-810-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA18153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: