Provider Demographics
NPI:1144977042
Name:GAMBOA, MARK ANTHONY JR (PTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:GAMBOA
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CREEKSIDE DR APT 2128
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3440
Mailing Address - Country:US
Mailing Address - Phone:209-623-9702
Mailing Address - Fax:
Practice Address - Street 1:2217 SUNSET BLVD STE 711
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4783
Practice Address - Country:US
Practice Address - Phone:916-435-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant