Provider Demographics
NPI:1215396650
Name:GUTIERREZ, ADRIAN (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:ADRIAN
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:MR
Other - First Name:ADRIAN
Other - Middle Name:
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 1669
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349
Mailing Address - Country:US
Mailing Address - Phone:928-722-6112
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1896 E BABBITT LN
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-722-6112
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-13
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8488363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ119514Medicaid