Provider Demographics
NPI:1801346465
Name:WILSON, GABRIEL
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:WILSON
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 1:943 GEARY ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-4904
Mailing Address - Country:US
Mailing Address - Phone:541-967-7844
Mailing Address - Fax:541-967-7844
Practice Address - Street 1:943 GEARY ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-4904
Practice Address - Country:US
Practice Address - Phone:541-967-7844
Practice Address - Fax:541-967-7844
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor