Provider Demographics
NPI:1811002462
Name:GUTIERRES, JASON EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:GUTIERRES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901
Mailing Address - Country:US
Mailing Address - Phone:505-894-7847
Mailing Address - Fax:505-894-7851
Practice Address - Street 1:414 MAIN STREET
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901
Practice Address - Country:US
Practice Address - Phone:505-894-7847
Practice Address - Fax:505-894-7851
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM460753356Medicaid
NM334515207Medicare PIN