Provider Demographics
NPI:1104924034
Name:GUTIERREZ, MIGUEL EDUARDO (PA)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:EDUARDO
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13204 NW 7TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2281
Mailing Address - Country:US
Mailing Address - Phone:786-313-0747
Mailing Address - Fax:786-313-0749
Practice Address - Street 1:3070 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4836
Practice Address - Country:US
Practice Address - Phone:786-313-0747
Practice Address - Fax:786-313-0749
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2926687-00Medicaid