Basic Information
| Provider Information | |||||||||
| NPI: | 1104973403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEBALLE | ||||||||
| FirstName: | REBECCA | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | MSC 10 6000 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722610 | ||||||||
| FaxNumber: | 5052721300 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 BRADBURY SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 02/05/2014 | ||||||||
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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 | 174400000X | AA2009-001 | NM | N | Other Service Providers | Specialist | 367H00000X | 004393 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 655260227A | 05 | GA | MEDICAID |