Provider Demographics
NPI:1023713435
Name:GUTIERREZ, LUCAS PENALOZA
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:PENALOZA
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 1:715 BRYSON RD
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9573
Mailing Address - Country:US
Mailing Address - Phone:828-767-7534
Mailing Address - Fax:
Practice Address - Street 1:3864 SWEETEN CREEK RD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-3136
Practice Address - Country:US
Practice Address - Phone:828-681-0904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8033225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty