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General NPI Number Information
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NPI Number | 1376073213
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Entity Type | Individual
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Provider Name | GABRIEL ISAAC WILSON I ATC
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Gender | Male
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Dates
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Enumeration Date | 06/13/2017
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Last Update Date | 06/13/2017
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Provider Practice Location Address
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Address Line | 13160 MINDANAO WAY STE 308
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City | MARINA DEL REY
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State | CA
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Zip | 90292-7907
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Country | US
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Telephone | 310-492-9355
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Fax |
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Provider Business Mailing Address
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Address Line | 3702 MOTOR AVE APT 19
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City | LOS ANGELES
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State | CA
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Zip | 90034-6584
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Country | US
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Telephone | 570-335-5102
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State | CA
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