Healthcare Provider Details

I. General information

NPI: 1558283036
Provider Name (Legal Business Name): LORD PRINCE LAURIE GABASA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 E 198TH ST
BRONX NY
10458-3147
US

IV. Provider business mailing address

708 W 177TH ST STE 4
NEW YORK NY
10033-6929
US

V. Phone/Fax

Practice location:
  • Phone: 347-270-9243
  • Fax:
Mailing address:
  • Phone: 646-360-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number051481
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: