Healthcare Provider Details

I. General information

NPI: 1174220438
Provider Name (Legal Business Name): ROBERT R GAMBOA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 CORDER RD STE 300
WARNER ROBINS GA
31088-7195
US

IV. Provider business mailing address

404 CORDER RD STE 300
WARNER ROBINS GA
31088-7195
US

V. Phone/Fax

Practice location:
  • Phone: 478-449-1475
  • Fax: 877-712-4794
Mailing address:
  • Phone: 478-449-1475
  • Fax: 877-712-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC008821
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: