MEDICARE: MR. GABRIEL WOLF RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	342137	OH

General Provider Information

NPI Number	:	1881947943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GABRIEL WOLF RN

Provider Business Mailing Address
First Line	:	205 CAMBRIDGESHIRE CT
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37615-4682
Country	:	US
Telephone Number	:	513-405-1989
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 CAMBRIDGESHIRE CT
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37615-4682
Country	:	US
Telephone Number	:	513-405-1989
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2012
Last Update Date	:	10/25/2012

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