Provider Demographics
NPI:1962950378
Name:GUTIERREZ, JOSE JR
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:GUTIERREZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATE ST
Mailing Address - Street 2:APT 2618
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3601
Mailing Address - Country:US
Mailing Address - Phone:309-335-4242
Mailing Address - Fax:
Practice Address - Street 1:59 GRENIER ST
Practice Address - Street 2:BUILDING 1507
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731
Practice Address - Country:US
Practice Address - Phone:339-202-6423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6716363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily