Provider Demographics
NPI:1093300774
Name:HERNANDEZ CARRASCO, GABRIEL RYAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:RYAN
Last Name:HERNANDEZ CARRASCO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 YALE BLVD SE STE A3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 YALE BLVD SE STE A3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4350
Practice Address - Country:US
Practice Address - Phone:505-385-8028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT4433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist