Healthcare Provider Details

I. General information

NPI: 1104973403
Provider Name (Legal Business Name): REBECCA GEBALLE AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 BRADBURY SE SUITE 2222
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3120
  • Fax: 505-272-8060
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAA2009-001
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number004393
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: