Provider Demographics
NPI:1164045027
Name:VARGAS, GABRIEL SR
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:VARGAS
Suffix:SR
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:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778-0903
Mailing Address - Country:US
Mailing Address - Phone:787-446-4072
Mailing Address - Fax:
Practice Address - Street 1:C17 CALLE MARGINAL
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6706
Practice Address - Country:US
Practice Address - Phone:787-780-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR290-PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant