Provider Demographics
NPI:1659033488
Name:GUTIERREZ, DIEGO A
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:A
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 1:12101 N LAMAR BLVD APT 334
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-1731
Mailing Address - Country:US
Mailing Address - Phone:954-464-3095
Mailing Address - Fax:
Practice Address - Street 1:12101 N LAMAR BLVD APT 334
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-1731
Practice Address - Country:US
Practice Address - Phone:954-464-3095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2159411225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant