Healthcare Provider Details

I. General information

NPI: 1841470135
Provider Name (Legal Business Name): GABRIEL A HERNANDEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 FOOTHILLS RD STE B
LAS CRUCES NM
88011-4672
US

IV. Provider business mailing address

3885 FOOTHILLS RD STE B
LAS CRUCES NM
88011-4672
US

V. Phone/Fax

Practice location:
  • Phone: 505-521-3388
  • Fax: 505-521-4023
Mailing address:
  • Phone: 505-521-3388
  • Fax: 505-521-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2003-0024
License Number StateNM

VIII. Authorized Official

Name: CYNTHIA LOPEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-521-3388