Provider Demographics
NPI:1275695538
Name:GUTIERREZ, GASTON ALBA (NP)
Entity Type:Individual
Prefix:
First Name:GASTON
Middle Name:ALBA
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 1:85 WEST HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO
Mailing Address - State:NM
Mailing Address - Zip Code:87052
Mailing Address - Country:US
Mailing Address - Phone:505-464-3060
Mailing Address - Fax:
Practice Address - Street 1:4201 MONTANO RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-5743
Practice Address - Country:US
Practice Address - Phone:505-866-3892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM01771363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24755761Medicaid
NMAU5186596OtherDEA
NM8HZB22Medicare PIN
NM8HZB12Medicare PIN
NM8HZA48Medicare PIN
NMAU5186596OtherDEA
NM8HZB42Medicare PIN
NM8HZB32Medicare PIN
NM8HZB22Medicare PIN