Provider Demographics
NPI:1528292398
Name:GUTIERREZ, ROBERT M (NP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-0520
Mailing Address - Country:US
Mailing Address - Phone:915-842-0504
Mailing Address - Fax:915-842-0448
Practice Address - Street 1:1721 N LEE TREVINO DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4563
Practice Address - Country:US
Practice Address - Phone:915-590-9424
Practice Address - Fax:915-590-9049
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX547503363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280350402Medicaid
TXTXB139147OtherINDIVIDUAL PTAN