Healthcare Provider Details

I. General information

NPI: 1013639475
Provider Name (Legal Business Name): GABRIEL MICHAEL WITT PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 2189
PAGO PAGO AMERICAN SAMOA
96799
UM

IV. Provider business mailing address

PO BOX 2189
PAGO PAGO AMERICAN SAMOA
96799
UM

V. Phone/Fax

Practice location:
  • Phone: 684-644-2642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0018598
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: