Provider Demographics
NPI:1245043504
Name:ORTIZ GUTIERREZ, KELVIN ROBERTO (714-PA)
Entity type:Individual
Prefix:
First Name:KELVIN
Middle Name:ROBERTO
Last Name:ORTIZ GUTIERREZ
Suffix:
Gender:M
Credentials:714-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. JARDINES DE COUNTRY CLUB
Mailing Address - Street 2:C-14 CALLE 9
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983
Mailing Address - Country:US
Mailing Address - Phone:787-224-8858
Mailing Address - Fax:
Practice Address - Street 1:AVE. BETANCES
Practice Address - Street 2:JK-14
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-778-5353
Practice Address - Fax:787-778-5353
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR714-PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant