Basic Information
| Provider Information | |||||||||
| NPI: | 1700242112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | GUSTAVO | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA | ||||||||
| Address2: | BLDG. A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S COUNTY LINE DR | ||||||||
| Address2: | |||||||||
| City: | CHAPARRAL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758240820 | ||||||||
| FaxNumber: | 5758241021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2016 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 363LP0200X | AP129867 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | CNP-02890 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 507110YRND | 01 | NM | MEDICARE | OTHER | 48681253 | 05 | NM | MEDICAID |