Healthcare Provider Details

I. General information

NPI: 1861865404
Provider Name (Legal Business Name): PHOOWANAI GAMBINO RDN, CDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33-41 NEWARK ST FL 5
HOBOKEN NJ
07030-5627
US

IV. Provider business mailing address

7917 32ND AVE # 1
EAST ELMHURST NY
11370-1831
US

V. Phone/Fax

Practice location:
  • Phone: 917-647-1665
  • Fax: 201-473-5812
Mailing address:
  • Phone: 917-647-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI200001566
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1101790
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: