Healthcare Provider Details

I. General information

NPI: 1366421133
Provider Name (Legal Business Name): ROGER GABRIEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W KINNICKINNIC RIVER PKWY #310
MILWAUKEE WI
53215-3677
US

IV. Provider business mailing address

2901 W KINNICKINNIC RIVER PKWY #310
MILWAUKEE WI
53215-3660
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-3990
  • Fax: 414-649-3969
Mailing address:
  • Phone: 414-649-3990
  • Fax: 414-649-3969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: