Provider Demographics
NPI:1780631119
Name:GUTIERREZ, EDUARDO (PA)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 LONG MDW
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-5929
Mailing Address - Country:US
Mailing Address - Phone:210-884-3308
Mailing Address - Fax:
Practice Address - Street 1:1301 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7533
Practice Address - Country:US
Practice Address - Phone:512-753-3796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9945OtherBCBS
TX8N9945OtherBCBS
TX8G5581Medicare PIN