Provider Demographics
NPI:1275270795
Name:CABRERA, NOEL CARCALLAS
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:CARCALLAS
Last Name:CABRERA
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 1:890 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3137
Mailing Address - Country:US
Mailing Address - Phone:650-583-7768
Mailing Address - Fax:
Practice Address - Street 1:890 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3137
Practice Address - Country:US
Practice Address - Phone:650-583-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9738225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant