Basic Information
| Provider Information | |||||||||
| NPI: | 1962694802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | WILSON | ||||||||
| MiddleName: | SY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2774 NW DAYSHA DR | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974712980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417846233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 10/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD28542 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | MD28542 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 208M00000X | MD28542 | OR | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.