Provider Demographics
NPI:1053425132
Name:HERNANDEZ, GABRIEL (PA)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3586
Mailing Address - Country:US
Mailing Address - Phone:310-329-8631
Mailing Address - Fax:310-329-8636
Practice Address - Street 1:1141 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 402
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3586
Practice Address - Country:US
Practice Address - Phone:310-329-8631
Practice Address - Fax:310-329-8636
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17831174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17831OtherPA LICENSE