Provider Demographics
NPI:1104869478
Name:GAMBONE, MATTHEW (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GAMBONE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 116TH AVE NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3058
Mailing Address - Country:US
Mailing Address - Phone:425-455-2131
Mailing Address - Fax:425-455-2335
Practice Address - Street 1:1810 116TH AVE NE
Practice Address - Street 2:SUITE D
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3058
Practice Address - Country:US
Practice Address - Phone:425-455-2131
Practice Address - Fax:425-455-2335
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1391507Medicaid
CO1391507Medicaid
COAB06569Medicare PIN