Provider Demographics
NPI:1124775812
Name:GUTZMER, MCKAYLA ROSE
Entity type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:ROSE
Last Name:GUTZMER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MCKAYLA
Other - Middle Name:ROSE
Other - Last Name:YENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:800-680-4369
Mailing Address - Fax:
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:800-680-4369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI7036-23207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program