Provider Demographics
NPI:1215554365
Name:LEWIS-KRAITSIK, GABRIEL SAGE (DPT)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:SAGE
Last Name:LEWIS-KRAITSIK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 1/2 ALARID ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104C OLD LAS VEGAS HWY
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-9301
Practice Address - Country:US
Practice Address - Phone:505-992-4995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-05
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist