=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487768271
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCIE N. GAMBOA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 07/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 GREEN VALLEY RD
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-724-7874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 GREEN VALLEY RD
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-724-7874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number | C41941
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------