Basic Information
| Provider Information | |||||||||
| NPI: | 1427600782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DURAZO | ||||||||
| FirstName: | GUSTAVO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 N F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203646852 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203643285 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2019 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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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 | 363LP2300X | 229416 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 583256 | 05 | AZ | MEDICAID |