Provider Demographics
NPI:1720671621
Name:GABRIEL, MARCUS QUINTON JR (PNP)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:QUINTON
Last Name:GABRIEL
Suffix:JR
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6924 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5256
Mailing Address - Country:US
Mailing Address - Phone:503-300-4111
Mailing Address - Fax:
Practice Address - Street 1:6924 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5256
Practice Address - Country:US
Practice Address - Phone:503-300-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202011094NP-PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty