Provider Demographics
NPI:1790355907
Name:TAKUH, GABRIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:TAKUH
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 1:1588 DRAYTON CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7293
Mailing Address - Country:US
Mailing Address - Phone:269-779-6415
Mailing Address - Fax:
Practice Address - Street 1:1588 DRAYTON CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-7293
Practice Address - Country:US
Practice Address - Phone:269-779-6415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704281691363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily