Provider Demographics
NPI:1538744347
Name:SUNRISE PATHOLOGY SERVICES
Entity type:Organization
Organization Name:SUNRISE PATHOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBBER-GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-243-4242
Mailing Address - Street 1:304 S JONES BLVD STE 7907
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2623
Mailing Address - Country:US
Mailing Address - Phone:702-213-5028
Mailing Address - Fax:702-675-9185
Practice Address - Street 1:304 S JONES BLVD STE 7907
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2623
Practice Address - Country:US
Practice Address - Phone:702-213-5028
Practice Address - Fax:702-675-9185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1902400104Medicaid
NV=========OtherIRS
OH=========Medicaid