Basic Information
Provider Information | |||||||||
NPI: | 1902066384 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GABRICK | ||||||||
FirstName: | ABIGALE | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JEFFREY | ||||||||
OtherFirstName: | ABIAGLE | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5803 NEAL AVE N | ||||||||
Address2: | OAK PARK HEIGHTS | ||||||||
City: | OAK PARK HEIGHTS | ||||||||
State: | MN | ||||||||
PostalCode: | 550822177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514398807 | ||||||||
FaxNumber: | 6514390232 | ||||||||
Practice Location | |||||||||
Address1: | 5803 NEAL AVE N | ||||||||
Address2: | OAK PARK HEIGHTS | ||||||||
City: | OAK PARK HEIGHTS | ||||||||
State: | MN | ||||||||
PostalCode: | 550822177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514398807 | ||||||||
FaxNumber: | 6514390232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2008 | ||||||||
LastUpdateDate: | 08/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2318 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 10464 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.