Provider Demographics
NPI:1013510775
Name:GAMBLE FAMILY MEDICAL PRACTICE
Entity type:Organization
Organization Name:GAMBLE FAMILY MEDICAL PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TANDALEO
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:918-760-2200
Mailing Address - Street 1:4134 S HARVARD AVE STE B3
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2613
Mailing Address - Country:US
Mailing Address - Phone:918-442-2236
Mailing Address - Fax:918-794-2333
Practice Address - Street 1:4134 S HARVARD AVE STE B3
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2613
Practice Address - Country:US
Practice Address - Phone:918-442-2236
Practice Address - Fax:918-794-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty