Provider Demographics
NPI:1720969181
Name:KAMBENJA, WATSON
Entity type:Individual
Prefix:
First Name:WATSON
Middle Name:
Last Name:KAMBENJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 CHATHAM ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-1766
Mailing Address - Country:US
Mailing Address - Phone:530-318-4889
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 7899
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96158-0899
Practice Address - Country:US
Practice Address - Phone:916-644-0951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036777363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty