Provider Demographics
NPI:1568682557
Name:CASANOVA, GABRIEL MANUEL JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:MANUEL
Last Name:CASANOVA
Suffix:JR
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 1:6990 NW 186TH ST APT 206
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3133
Mailing Address - Country:US
Mailing Address - Phone:305-904-2704
Mailing Address - Fax:
Practice Address - Street 1:11200 SW 8TH ST
Practice Address - Street 2:PHARMED ARENA 156
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33199-0001
Practice Address - Country:US
Practice Address - Phone:305-348-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL14602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL1460Medicaid
FLAL1460OtherATHLETIC TRAINER
FLAL1460OtherATHLETIC TRAINER
FLAL1460Medicare ID - Type UnspecifiedATHLETIC TRAINER