Healthcare Provider Details

I. General information

NPI: 1730694803
Provider Name (Legal Business Name): SAUL RAMIREZ GAMBOA JR. FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/14/2019
Certification Date: 12/14/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W 24TH ST
PLAINVIEW TX
79072-1802
US

IV. Provider business mailing address

5711 2ND ST
LUBBOCK TX
79416-1503
US

V. Phone/Fax

Practice location:
  • Phone: 806-293-5165
  • Fax:
Mailing address:
  • Phone: 432-210-1076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP135451
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: