Healthcare Provider Details

I. General information

NPI: 1578214789
Provider Name (Legal Business Name): GABRIEL PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STATION WAY STE E
ARROYO GRANDE CA
93420-3348
US

IV. Provider business mailing address

200 STATION WAY STE E
ARROYO GRANDE CA
93420-3348
US

V. Phone/Fax

Practice location:
  • Phone: 805-202-7336
  • Fax: 805-202-7153
Mailing address:
  • Phone: 805-202-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95019600
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95019600
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95019600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: