Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 2694 | OK |
NPI | 1114549920 |
---|---|
Provider Name | Mr. Jose L Gamboa JR. |
First Address | Oklahoma City, OK 73114-4312 |
Second Address | Oklahoma City, OK 73162-5509 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2020 |
Last Update Date | 14/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G082973974 | DRIVERS LICENSE (01) | OK |