Provider Demographics
NPI:1376073213
Name:WILSON, GABRIEL ISAAC I (ATC)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:ISAAC
Last Name:WILSON
Suffix:I
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 MOTOR AVE APT 19
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6584
Mailing Address - Country:US
Mailing Address - Phone:570-335-5102
Mailing Address - Fax:
Practice Address - Street 1:13160 MINDANAO WAY STE 308
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7907
Practice Address - Country:US
Practice Address - Phone:310-492-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty