Healthcare Provider Details

I. General information

NPI: 1184263303
Provider Name (Legal Business Name): SETH TYLER GAMBONE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

IV. Provider business mailing address

7400 SAN PEDRO DR NE APT 1069
ALBUQUERQUE NM
87109-4691
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-8000
  • Fax:
Mailing address:
  • Phone: 614-633-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number58681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: