Provider Demographics
NPI:1427401652
Name:GABRIEL, OMAR JERICO (ANP)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:JERICO
Last Name:GABRIEL
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 KIERSTEN LN
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-0609
Mailing Address - Country:US
Mailing Address - Phone:928-279-9387
Mailing Address - Fax:
Practice Address - Street 1:3204 KIERSTEN LN
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-0609
Practice Address - Country:US
Practice Address - Phone:928-279-9387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8848363LA2100X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology