Basic Information
| Provider Information | |||||||||
| NPI: | 1689610248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAMBAROTA | ||||||||
| FirstName: | MARCI | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 E. NIZHONI BLVD. | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 02/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD424787 | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD2006-0438 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 961567 | 05 | AZ | MEDICAID | 76226239 | 05 | NM | MEDICAID |