Provider Demographics
NPI:1104973403
Name:GEBALLE, REBECCA (AA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GEBALLE
Suffix:
Gender:
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:933 BRADBURY SE
Practice Address - Street 2:SUITE 2222
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-3120
Practice Address - Fax:505-272-8060
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAA2009-001174400000X
GA004393367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA655260227AMedicaid
GA32BBBLHMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER