Healthcare Provider Details

I. General information

NPI: 1518775543
Provider Name (Legal Business Name): PETRONILO GUMBAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 WHEELING ST
AURORA CO
80045-7211
US

IV. Provider business mailing address

4139 S LIVERPOOL WAY
AURORA CO
80013-7460
US

V. Phone/Fax

Practice location:
  • Phone: 303-218-0752
  • Fax:
Mailing address:
  • Phone: 303-218-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.0183597
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: