Provider Demographics
NPI:1073114674
Name:MUTUKU, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:MUTUKU
Suffix:
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 1:188 NH 101
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-5451
Mailing Address - Country:US
Mailing Address - Phone:603-314-4700
Mailing Address - Fax:
Practice Address - Street 1:188 NH 101
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5451
Practice Address - Country:US
Practice Address - Phone:603-314-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH072247-23363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology