Provider Demographics
NPI:1720030406
Name:HUTSELL, GENE C (NP)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:C
Last Name:HUTSELL
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:PO BOX 813
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-0813
Mailing Address - Country:US
Mailing Address - Phone:928-669-6669
Mailing Address - Fax:
Practice Address - Street 1:1125 PUEBLO DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-8918
Practice Address - Country:US
Practice Address - Phone:928-669-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN114639163W00000X
WAAP30004998363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30004998OtherWA STATE
AZ646995OtherAHCCCS
S91808Medicare UPIN
AZ78749Medicare ID - Type UnspecifiedYUMA COUNTY