Provider Demographics
NPI:1902672348
Name:GAMOL, ALISSA PAULA SEBASTIAN
Entity Type:Individual
Prefix:
First Name:ALISSA PAULA
Middle Name:SEBASTIAN
Last Name:GAMOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 BRIARWOOD AVE APT D306
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-2656
Mailing Address - Country:US
Mailing Address - Phone:432-276-0711
Mailing Address - Fax:
Practice Address - Street 1:2501 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6436
Practice Address - Country:US
Practice Address - Phone:432-203-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1286600208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation