Provider Demographics
NPI:1699342014
Name:HERNANDEZ, GABRIEL
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:HERNANDEZ
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 1:3027 BRIDGEPORT WAY W APT A
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4643
Mailing Address - Country:US
Mailing Address - Phone:949-500-5077
Mailing Address - Fax:
Practice Address - Street 1:N 19TH ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS-MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:949-500-5077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1614574912255A2300X
CA390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer