MEDICARE: JERRY ANN BALBOA GUMABON

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	363LF0000X	Family Nurse Practitioner	824950	NV

General Provider Information

NPI Number	:	1407651219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY ANN BALBOA GUMABON

Provider Business Mailing Address
First Line	:	5216 BOULDER HWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6074
Country	:	US
Telephone Number	:	702-547-6764
Fax Number	:

Provider Business Practice Location Address
First Line	:	5216 BOULDER HWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6074
Country	:	US
Telephone Number	:	702-547-6764
Fax Number	:

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

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	06/14/2025

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