Provider Demographics
NPI:1073262549
Name:WIRTZ FIERRO, GABRIEL RAY
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:RAY
Last Name:WIRTZ FIERRO
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 1:3039 MINERAL WELLS CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1823
Mailing Address - Country:US
Mailing Address - Phone:805-416-4028
Mailing Address - Fax:
Practice Address - Street 1:11550 INDIAN HILLS RD STE 261
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1244
Practice Address - Country:US
Practice Address - Phone:818-847-6570
Practice Address - Fax:310-582-7495
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA61070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant