Provider Demographics
NPI:1073977625
Name:GUTIERREZ, NICHOLAS RAYMOND (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:RAYMOND
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 EMILIO LOPEZ RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7082
Mailing Address - Country:US
Mailing Address - Phone:505-865-4646
Mailing Address - Fax:
Practice Address - Street 1:1776 EMILIO LOPEZ RD NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7082
Practice Address - Country:US
Practice Address - Phone:505-865-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM587174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist