Provider Demographics
NPI:1609886316
Name:GABRIELSON, MARY H (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:H
Last Name:GABRIELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W FOREST AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1479
Mailing Address - Country:US
Mailing Address - Phone:928-773-2505
Mailing Address - Fax:928-773-2504
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:928-773-2505
Practice Address - Fax:928-773-2504
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20609207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104977Medicaid
AZ104977Medicaid
AZWCKDQ02Medicare PIN
AZF28391Medicare UPIN
AZZWCKDQ02Medicare PIN