Provider Demographics
NPI:1194380352
Name:GABRIEL, MICHAEL RICHARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:GABRIEL
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 1:4990 SANDALWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5910
Mailing Address - Country:US
Mailing Address - Phone:315-956-5298
Mailing Address - Fax:
Practice Address - Street 1:4990 SANDALWOOD LN
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-5910
Practice Address - Country:US
Practice Address - Phone:315-956-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant