Provider Demographics
NPI:1528101375
Name:GAMBOA, MIRNA (DC)
Entity type:Individual
Prefix:DR
First Name:MIRNA
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 E CHARLESTON BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6625
Mailing Address - Country:US
Mailing Address - Phone:702-478-6914
Mailing Address - Fax:702-478-6915
Practice Address - Street 1:3230 E CHARLESTON BLVD STE 109
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6625
Practice Address - Country:US
Practice Address - Phone:702-478-6914
Practice Address - Fax:702-478-6915
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor