Provider Demographics
NPI:1609143460
Name:GUTIERREZ, RAUL J (ACNP)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:J
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:440 RAYNOLDS ST # 51015
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1613
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:S4604
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1619
Practice Address - Country:US
Practice Address - Phone:413-794-5550
Practice Address - Fax:413-794-9294
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX747453363LA2100X
UT747453363LA2100X
MA2292209363LA2100X
VA0024188097363LA2100X, 363LA2200X, 363LG0600X
TXAP121166363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX294114YKWUMedicare PIN
TX294114YMVQMedicare PIN
TX1609143460OtherBLUE CROSS BLUE SHIELD
TX288067605Medicaid