Basic Information
| Provider Information | |||||||||
| NPI: | 1215396650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | ADRIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUTIERREZ | ||||||||
| OtherFirstName: | ADRIAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1669 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287226112 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1896 E BABBITT LN | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287226112 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2016 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP8488 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 119514 | 05 | AZ | MEDICAID |