Basic Information
| Provider Information | |||||||||
| NPI: | 1003806472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 S. DON ROSER DR. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755213388 | ||||||||
| FaxNumber: | 5755214023 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 S. DON ROSER DR. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755213388 | ||||||||
| FaxNumber: | 5755214023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 09/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2003-0024 | NM | N | Other Service Providers | Specialist | 2084P0800X | NM2003-0024 | NM | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 99930722 | 05 | NM | MEDICAID |