MEDICARE: MARIA GEINAH LABANERO GUMBAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00010536	WA

General Provider Information

NPI Number	:	1306547989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA GEINAH LABANERO GUMBAN

Provider Business Mailing Address
First Line	:	125 DALLAS ST
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-3014
Country	:	US
Telephone Number	:	360-630-7517
Fax Number	:

Provider Business Practice Location Address
First Line	:	1105 27TH ST
Second Line	:
City	:	ANACORTES
State	:	WA
Zip	:	98221-2710
Country	:	US
Telephone Number	:	360-293-3174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	03/13/2023

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