Provider Demographics
NPI:1922604115
Name:SEVALIE, GABRIEL MARTIN
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:MARTIN
Last Name:SEVALIE
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 1:4211 SUGAR PINE CT
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-1153
Mailing Address - Country:US
Mailing Address - Phone:240-421-2538
Mailing Address - Fax:
Practice Address - Street 1:4211 SUGAR PINE CT
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-1153
Practice Address - Country:US
Practice Address - Phone:240-421-2538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173970363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner