Provider Demographics
NPI:1548823909
Name:GAMBOA GONZALEZ, JOSE RAFAEL (SA-C)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:RAFAEL
Last Name:GAMBOA GONZALEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17877 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-4402
Mailing Address - Country:US
Mailing Address - Phone:954-513-9853
Mailing Address - Fax:
Practice Address - Street 1:17877 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-4402
Practice Address - Country:US
Practice Address - Phone:954-513-9853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-20
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-201246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant