Provider Demographics
NPI:1093053449
Name:GUTIERREZ, EDGAR ALLAN
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ALLAN
Last Name:GUTIERREZ
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 1:5750 SE TRANQUIL CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-4343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8122 SE TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1768
Practice Address - Country:US
Practice Address - Phone:503-255-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200341187-RN163W00000X
OR201405804NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse