Provider Demographics
NPI:1386781573
Name:GUTIERREZ, MARK ANTHONY BAUTISTA (PT)
Entity type:Individual
Prefix:
First Name:MARK ANTHONY
Middle Name:BAUTISTA
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5430
Mailing Address - Country:US
Mailing Address - Phone:516-270-3110
Mailing Address - Fax:
Practice Address - Street 1:625 STEWART AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-5430
Practice Address - Country:US
Practice Address - Phone:516-270-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0240771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist